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vein  in  the  inter 

glandular  con 

nective  tissue 

between  first  and 

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lai'is  mucos  b 

in  center  of  Uie 

drawing. 


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thelium of  the 
gastric  surface. 


Vestibule 
(Vorramn.') 


Exit  of  gland 
duct. 


The  darker 
stained  are  the 
parietal, border 
or  oxyntic  cells, 
showing  commu- 
nication with  the 

central  giand 

duct.  The  lighter 

are  the  central. 

I  hief  or  ferment 

cells. 


Break  in  contin- 
uity of  central 
duct,  due  to  curv- 
ing away  of  the 
g-land  tubule 
from  the  plane 
of  section. 


Between  the 
longitudinal  tu- 
bules 2  cross  and 
2  tangent  sec- 
tions of  peptic 
diicts. 


cnsa-  einbracmg 

base  of  the  peptic 

gland. 


T..nmitii,linMlnnd 

rinss-rr!i,.n  "f 


Subuiucosa 
with  arterioles. 


HEM.MKILK  HI  1 


VERTICAL  SECTION   THKOUGH   NORilAL  HUMAN 
GASTKIC   MUCOSA. 


DISEASES 


STOMACH 


THEIR    SPECIAL    PATHOLOGY,    DIAGNOSIS,    AND    TREATMENT, 
WITH  SECTIONS  ON  ANATOMY,  PHYSIOLOGY,  CHEMI- 
CAL AND  MICROSCOPICAL  EXAMINATION  OF 
STOMACH  CONTENTS,  DIETETICS,  SUR- 
GERY OF  THE  STOMACH,  ETC. 


BY 

JOHN  C.   HEMMETER,  M.D.,  Philos.D. 

PROFESSOR  IN  THE  MEDICAL  DEPARTMENT  OF  THE  UNIVERSITY  OF  MARYLAND,  BALTIMORE;  CONSULTANT 

TO    THE   UNIVERSITY    HOSPITAL,   AND    DIRECTOR   OF  THE   CLINICAL   LABORATORY; 

AUTHOR   OF   "  A  TREATISE   ON   DISEASES   OF   THE   INTESTINES,"    ETC. 


WITH    MANY    ORIGINAL    ILLUSTRATIONS 

A   NUMBER   OF   WHICH   ARE   IN  COLORS 

AND    A    LITHOGRAPH    FRONTISPIECE 


Ubir^  Bnlaroeb  an^  1Revise&  BDition 


PHILADELPHL\ 
P.    BLAKISTON'S   SON    cH:    CO. 

IOI2     WALNUT     STREET 
1902 


Copyright,  1902,  by  P.  Blakiston's  Son  &  Co. 


press  of  wm.  f.  fell  4  co 

1220-24  Sansom  Street, 

philadelphia. 


THE  BELLY  AND  THE  MEMBERS 


The  members  of  the  body  rebelled  against  the  Belly,  and 
said,  "Why  should  we  be  perpetually  engaged  in  administer- 
ing to  your  wants,  while  you  do  nothing  but  take  your  rest 
and  enjoy  yourself  in  luxury  and  self-indulgence?"  The 
members  carried  out  their  resolve,  and  refused  their  assistance 
to  the  Belly.  The  whole  body  quickly  became  debilitated, 
and  the  hands,  feet,  mouth,  and  eyes,  when  too  late,  repented 
of  their  folly. — JEsop. 


3AlblS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/detaNs/diseasesofstomac1902hemm 


TO 

PROFESSOR   WILLIAM    OSLER,  M.D., 

OF    BALTIMORE 

(II  maestro  di  color  che  sanno. — Daiite), 

THIS     VOLUME     IS     RESPECTFULLY 
DEDICATED. 


PREFACE  TO  THIRD  EDITION. 


In  a  work  that  is  essentially  a  record  of  practice,  and  intended  for 
practice,  the  main  object  for  a  new  edition  must  be  to  sift  the  wheat 
from  the  chaff  in  the  new  publications  on  this  subject  that  have  ap- 
peared since  the  last  previous  edition.  Much  emphasis  has  been 
placed  upon  the  factor  of  differential  diagnosis,  and  new  material  has 
been  added  to  the  chapters  on  ulcer  and  carcinoma,  and  a  new  article 
on  Gastric  Lipase. 

The  reception  which  previous  editions  have  met  with  in  this  coun- 
try and  Europe  has  exceeded  the  most  sanguine  expectations.  If  I 
shall  have  accomplished  a  work  of  use  for  the  general  practitioner  and 
enabled  him  to  keep  abreast  of  modern  progress  in  this  special  line, — 
an  aim  which  the  success  of  the  previous  editions  encourages  me  to 
hope  for  this  edition, — I  will  feel  fully  recompensed  for  the  work  and 
labor  bestowed  upon  this  volume. 


Baltimore,  May  i,  jgo2. 


"  Prodesse  quam  conspiciy 

The  Author. 


PREFACE  TO  SECOND  EDITION. 


The  exhaustion  of  the  first  edition  of  this  book  made  a  call  for  a 
revision  necessary  in  a  little  over  one  year  from  the  date  of  its  pub- 
lication. Owing,  however,  to  serious  illness  in  the  author's  imme- 
diate family,  it  was  impossible  to  comply  promptly  with  the  request 
of  the  publishers.  The  whole  book  has  been  gone  over  critically 
four  times  by  the  author  and  his  associate.  Dr.  Harry  Adler,  and 
there  are  probably  not  fifty  pages  in  which  some  important  insertion 
or  alteration  has  not  been  made.  About  two-thirds  of  the  book 
has  been  actually  reconstructed,  and  a  large  amount  of  new  material 
added,  of  which  the  following  articles  are  the  most  important :  Hyper- 
trophic Stenosis  of  the  Pylorus,  Obstruction  of  the  Orifices,  The  Use 
and  Abuse  of  Rest  and  Exercise  in  the  Treatment  of  Digestive  Dis- 
eases, part  of  the  chapter  on  Motor  Insufficiency,  Klectrodiaphany, 
Hemorrhage  from  Stomach,  and  the  articles  on  Gastroptosis  and 
Enteroptosis  have  been  entirely  rewritten. 

New  illustrations  and  plates,  being  the  work  of  Mr.  Louis  Schmidt 
and  Mr.  Herman  Becker,  have  been  inserted  on  the  following  sub- 
jects :  Hypertrophic  Stenosis  of  the  Pylorus  from  Chronic  Stenosing 
Gastritis;  Actual  Size  and  Configuration  of  the  Stomach  in  a  State 
of  Hyperplastic  Stenosing  Gastritis;  Malformation  and  Distortion 
of  Thorax  and  Stomach  Caused  by  Lacing,  Tight  Clothing,  etc.; 
Adhesions  Causing  Motor  Insufficiency;  Gastric  Distention  by  CO2, 
Showing  the  Stomach  in  a  State  of  Gastroptosis;  Connective-tissue 
Hyperplasia  Separating  Remnants  of  Peptic  Glands;  Detachment 
of  Secretory  Cells;  Mechanism  Effecting  Vertical  Position  of  the 
Stomach. 

A  text-book  that  undergoes  subsequent  editions  is  the  product 
of  the  evolution  of  thought,  not  only  of  its  author,  but  of  that  part 
of  the  medical  profession  which  is  active  in  its  special  domain.  While 
the  book  bears  the  impress  of  the  author's  individuality,  it  should, 


xu  preface;  to  second  edition. 

if  possible,  be  an  exponent  of  the  total  practical  knowledge  that  has 
been  gained.     As  Riegel  says, 

"  The  final  object  of  all  medical  activity  is  to  help  and  to  heal.  The  practitioner  has 
the  right  to  estimate  the  progress  in  any  domain  of  medicine  by  the  gain  that  has  accrued 
to  the  healing  art." 

In  the  author's  opinion  the  most  useful  feature  of  this  second  edi- 
tion is  the  repeated  and  thorough  application  of  mature  and  critical 
judgment  to  the  entire  subject-matter  of  the  book.  It  is  not  intended 
that  this  should  be  a  scientific  work  in  the  technical  sense  of  the  term, 
the  question  that  weighed  most  heavily  upon  the  author's  conscience 
being,  "How  much  can  I  aid  the  practitioner  in  his  efforts  toward 
belping  and  healing  others?" 

I  am  indebted  to  the  distinguished  American  clinician,  to  whom 
this  book  is  dedicated,  Professor  William  Osier,  for  much  cordial 
encouragement  and  many  useful  suggestions,  given  both  personally 
and  by  correspondence.  To  my  associate,  Dr.  Harry  Adler,  I  wish 
to  express  thanks  for  the  unceasing  vigilance  which  he  exercised  in 
the  proof-reading  and  for  the  application  of  conservative  critical  judg- 
ment throughout  the  entire  book,  and  especially  to  the  paragraphs 
on  Clinical  Pathology.  To  Dr.  F.  P.  Mall  for  advice  relating  to 
chapter  on  the  Anatomy  of  the  Digestive  Organs.  To  Dr.  Edward 
L.  Whitney  I  am  indebted  for  rewriting  the  chemical  section  of  Part 
I.  To  Dr.  Henry  W.  Nolte  (now  of  Newark,  N.  J.)  and  Mr.  Thomas 
H.  Cannon  for  arranging  the  index  of  subjects  and  index  of  authors. 
To  the  medical  faculty  of  the  University  of  Maryland  I  am  indebted  for 
the  unrestricted  use  of  the  clinical  and  pathological  material  of  the 
University  Hospital  and  their  generous  support  of  the  clinical  labor- 
atory, in  which  much  of  the  newer  material  was  clinically  and  ex- 
perimentally tested. 

The  almost  daily  association  with  clinicians  of  experience  and 
ability  gives  a  feeling  of  enthusiasm,  which  is  a  powerful  auxiliary 
to  an  author,  and  marvelously  diminishes  his  toil;  in  the  language 
of  Ovid — 

"  Scribentem  juvat  ipse  favor,  minuitque  laborem  ; 
Cumque  suo  crescens  peclora  fervet  opus." 

The  Author. 
Baltimore,  March,  jgoo. 


PREFACE  TO  FIRST  EDITION. 


The  tendency  of  modern  science — not  only  of  medica;!  science — 
is  toward  specialization. 

Diseases  of  the  stomach  alone  is  not  a  field  sufficiently  large  tO' 
constitute  a  genuine  specialty.  It  is  generally  associated  with  the 
study  of  the  diseases  of  all  digestive  organs,  particularly  of  the  in- 
testines, liver,  and  pancreas.  The  diseases  of  metabolism  constitute 
a  legitimate  field  naturally  falling  into  the  domain  of  the  digestive 
clinical  pathologist. 

In  an  address  before  the  Medical  and  Chirurgical  State  Faculty 
of  Maryland  in  April,  1896,  Professor  Da  Costa,  in  speaking  of  the 
manner  in  which  medical  libraries  build  up  and  increase,  said  that 
"books  attract  books,  and,  as  a  rule,  any  new  work  in  any  particular 
class  has  a  striking  family  resemblance  to  those  already  published." 

If  this  new  contribution  to  the  pathology  and  treatment  of  organic 
diseases  of  the  stomach  does  not  conform  to  Da  Costa's  generaliza- 
tion, it  is  not  because  of  any  premeditated  plan  to  make  it  different 
from  other  works  on  the  same  subject,  but  because  a  number  of 
entirely  new  methods  of  diagnosis  have  entered  into  it,  and  because 
an  attempt  has  been  made  to  do  justice  to  the  work  of  American 
clinicians  in  this  special  department.  My  chief  effort  has  been  to 
furnish  the  general  practitioner  with  a  work  from  which  he  can 
readily  acquaint  himself  with  all  that  has  been  done  in  this  important 
branch  of  medicine,  to  fit  himself  to  make  examinations,  to  take 
advantage  of  new  methods  of  diagnosis,  and  to  treat  this  very  difficult 
class  of  diseases  rationally  and  successfully. 

With  this  end  in  view  I  have  endeavored  to  treat  the  subject 
systematically  and  concisely,  giving  first  the  special  anatomy  and 
physiology  of  the  digestive  organs,  methods  of  diagnosis  and  general 
therapy,  including  dietetics,  following  this  by  a  methodical  discussion 
of  the  various  diseases  affecting  the  stomach,  with  their  symptoma- 
tolog}^,  diagnosis,  prognosis,  pathology,  and  treatment.     The  illus- 


XIV  PREI^'ACE   TO    FIRST   EDITION. 

trations,  of  wliich  many  are  from  original  drawings,  have  been  se- 
lected because  of  their  practical  bearing  upon  the  matter  in  hand. 

Aside  from  the  fact  that  the  pathology,  diagnosis,  and  therapy 
of  diseases  of  the  human  organs  have  become  so  extensive  that  it 
is  absolutely  impossible  for  one  mind  to  master  them  all,  genuine 
advances  in  any  particular  department  have  hitherto  been  made 
only  by  such  scholars  as  could  concentrate  and  focus  their  mental 
energy  upon  a  limited  subject. 

Experience  of  the  last  twenty-five  years  has  demonstrated  that 
the  general,  fundamental  stock  of  medical  knowledge  has  not  been 
injured,  but,  on  the  contrary,  it  has  been  wonderfully  enlarged  and 
strengthened  by  the  progress  in  strictly  special  fields  of  work. 

To  read  the  history  of  the  development  of  medical  sciences,  the 
frequently  astonishing  results  and  indefatigable  perseverance  of 
"the  grand  old  men  of  medicine,"  is  not  only  a  healthy  training 
for  prospective  investigators,  but  can  not  fail  to  polish  down  the 
pride  of  the  overambitious. 

Speaking  purely  from  a  therapeutic  standpoint,  however,  our 
medical  ancestors  of  the  beginning  of  this  century  were  for  the  greater 
part  divided  into  two  extreme  classes:  First,  the  polypharmacists ; 
second,  the  skeptics,  the  therapeutic  nihilists.  It  is  largely  the 
credit  of  the  specialties  that  Asclepiads  have  evolved  from  this  con- 
fused opposition.  It  was  an  unspeakable  comfort  to  be  reassured 
by  Virchow  and  others  that,  after  all,  the  end  object,  the  funda- 
mental purpose,  of  all  medical  progress  must  be  the  rehef  of  suffer- 
ing and  the  cure  of  disease,  not  simply  the  development  of  abstract 
science.  A  further  step  in  the  evolution  of  therapy  was  the  reali- 
zation that  the  object  of  medical  study  and  treatment  must  not  be 
the  "disease,"  but  the  diseased  patient.  Specialties  can  not  make 
the  adept  one-sided,  nor  obscure  his  view  of  the  general  body  of 
medical  knowledge;  on  the  contrary,  the  detailed  development  of 
the  intellect  which  results  from  concentration  of  energy  upon  one 
subject  will  enlarge  his  powers  of  observation  and  analysis  and  insure 
a  more  comprehensive  understanding  of  the  totality  of  general 
medicine.  Boerhaave  could  claim  to  be  master  of  all  applied  medical 
branches;  lyangenbeck  and  Frerichs  were  credited  with  absolute 
mastership  in  three  or  four  heterogeneous  branches  of  medicine. 
Medicine  has  been  enormously  developed  since  those  days.  Who 
will  claim  such  mastery  at  the  present  time?  Bach,  Mozart,  and 
Haydn   were   acknowledged   virtuosi   on   five   or   six   instruments. 


PREF'ACE   TO    FIRST   EDITION.  XV 

Where  is  such  a  phenomenal  genius  of  the  present  day  in  music? 
The  enlargement  of  any  branch  of  human  knowledge  or  art  brings 
specialization  with  it  as  a  natural  sequence;  that  this  tendency  is 
a  blessing  for  the  central,  fundamental  stock  of  knowledge,  sci- 
ence, or  art  has  been  proved  in  many  branches.  Perhaps  as  good 
an  evidence  of  this  fact  as  any  is  the  advantage  which  general  med- 
icine is  just  beginning  to  reap  from  the  brilliant  results  of  bacteri- 
ology. 

When  the  printing  of  this  book  was  begun,  there  was  no  work 
of  American  origin  on  this  subject.  Since  then  the  volume  by  Ein- 
horn  has  appeared,  being  a  compilation  of  the  monographs  by  this 
author  in  the  "Twentieth  Century  Practice  of  Medicine." 

We  already  have  a  large  number  of  eminently  qualified  and  ver- 
satile clinicians,  men  with  acute  observing  powers  and  analytical 
minds,  who  have  worked  in  this  interesting  field.  The  names  of 
Austin  Flint,  Pepper,  Osier,  and  Delafield  Fitz  are  as  well  known 
in  this  department  in  our  country  as  those  of  Kussmaul,  Senator, 
Nothnagel,  Leube,  Ewald,  and  Boas  in  Germany,  or  Hayem,  Bou- 
veret,  Debove,  and  Mathieu  in  France. 

Among  those  who  have  made  contributions  of  note  to  this  special 
line  of  work  are  S.  Meltzer,  Einhorn,  George  Dock,  W.  D.  Booker, 
Charles  G.  Stockton,  Allen  Jones,  D.  D.  Stewart,  Julius  Friedenwald, 
Francis  P.  Kinnicut,  F.  B.  Turck,  Charles  E.  Simon,  and  other  gifted 
experimenters  and  clinicians. 

The  anatomy  of  the  stomach  has  received  a  lasting  benefit  through 
the  intellect  of  F.  Mall,  of  Baltimore. 

The  surgery  of  the  alimentary  tract  has  many  very  creditable 
representatives  in  our  country,  among  whom  may  be  mentioned 
W.  W.  Keen,  Robert  F.  Weir,  N.  Senn,  John  B.  Deaver,  McBurney, 
Roswell  Park,  F.  Lang,  R.  Abbe,  W.  Meyer,  Murphy,  Bull,  Maurice 
H.  Richardson,  W.  S.  Halsted,  Gerster,  and  John  M.  T.  Finney. 
The  literary  and  practical  contributions  of  a  number  of  these  men 
have  reached  a  classic  standard  and  compelled  foreign  admiration. 

The  physiological  chemistry  of  digestion  and  internal  secretion 
has  received  the  benefit  of  the  work  of  Bowditch,  Chittenden,  Howell, 
Vaughn,  Adami,  Able,  and  others,  and  dietetics  has  its  versatile 
representative  in  Gilman  Thompson. 

To'  Messrs.  Blakiston,  Sen  &  Co.,  the  pubhshers,  the  author  feels 
sincerely  grateful.  It  would  be  a  neglect  to  omit  an  expression  of 
this  feeling.     The  manner  in  which  they  have  executed  their  part 


XVI  preface;  to  first  edition. 

of  the  work  speaks  for  itself.  It  is  a  great  pleasure  for  an  author 
to  be  able  to  work  with  such  intelligent  and  enthusiastic  publishers. 

To  Dr.  Edward  L.  Whitney,  my  associate,  it  becomes  my  pleasant 
duty  to  express  thanks  for  the  able  manner  in  which  he  has  written 
the  chemical  section  of  part  first,  and  also  for  much  kind  assistance 
throughout  the  work. 

Pathology  has  its  men  now  universally  acknowledged  for  the 
integrity  and  dignity  of  their  work  in  our  esteemed  teachers,  Welch 
and  Councilman.  Already  an  American  School  of  Pathology  is 
forming,  with  these  men  and  Prudden,  Flexner,  and  others.  But  in 
the  special  pathology  of  the  digestive  organs  the  workers  are  few; 
a  very  creditable  beginning,  however,  has  been  made;  the  founda- 
tion is  an  honor  to  the  prospective  builders,  but  the  land  to  be  ex- 
plored is  exceedingly  large  in  its  extent,  and  "the  harvest  is  plenteous, 
but  the  laborers  are  few." 

JOHN  C.  HBMMETER. 

Baltimore,  1897. 


"  Heard  are  the  voices, 
Heard  are  the  sages. 
The  worlds  and  the  ages  ; 
Choose  well,  your  choice  is 
Brief  and  yet  endless. 

"  Here  eyes  do  regard  you 
In  eternity's  stillness. 
Here  is  all  fullness, 
Ye  brave,  to  reward  you  ; 
Work  and  despair  not. ' ' 

—  Goethe 


LIST  OF  ILLUSTRATIONS, 


Normal  Histology  of  the  Gastric  Mucosa, Frontispiece. 

I.  Three  Sections  of  Stomach-walls  Placed  Side  by  Side  to  Show  the  Positions 
of  Blood-vessels  and  Lymphatics  to  the  Different  Layers  [Colored), 

Opposite  Page       28 
IL   Reconstruction  of  a    Small    Portion  of  the  Middle  Zone  of  the  Stomach 

[^Colored),      Opposite  Page       28 

III.  Patient  with  Intragastric  Bag  within  Stomach  and  Pneumograph  in  Place, 

Both  Connected  with  the  Kymograph, Opposite  Page      76 

IV.  Apparatus,  not  Including  Kymograph, Opposite  Page      76 

V.  Stomach  Distended  by  Air  or  COj,  Showing  Stomach  in  State  of  Gastrop- 

tosis, 106 

VI.   Phlegmonous  Gastritis  in  the  Sequence  of  Ulcus  Carcinomatosum, 

Opposite  Page    436 

VII.  Bacterial  Invasion  of  Gastric    Epithelium.      From  a    Case   of  Diphtheric 

Gastritis  {^Colored), Opposite  Page    440 

VIII.  Carcinomatous  Ulcer  of  the  Pyloric  Antrum,  .......  Opposite  Page    490 

IX.   Ulcus  Carcinomatosum  of  the  Pylorus,  Opposite  Page    506 

X.  Syphilitic    Gastritis,   Showing   Degeneration  and   Loss  of  the   Superficial 

Columnar  Epithelium  and  That  of  the  Vestibules,  etc.,  .    .  Opposite  Page    596 
XI.   Hypertrophic  Stenosis  of  the   Pylorus  from  Chronic  (Stenosing)  Gastritis, 

Opposite  Page    618 
XII.  Stenosing  Hypertrophic  Gastritis,  Actual  Size  and  Configuration  of  Stom- 
.  ach  Opened  along  the  Lesser  Curvature  from  Esophagus  to  Duodenum, 

Opposite  Page    620 
XIIL  Malformation  and  Distortion  of  the  Stomach  Caused  by  Lacing  or  Tight 

Clothing,  Belts,  etc., Opposite  Page    628 

XIV.   Gastrectasia,  Transillumination  of  the  Stomach, Opposite  Page    640 

XV.  Adhesions,  Causing  Motor  Insufficiency  but  Retaining  Stomach  in  Normal 

Position, Opposite  Page    642 


FIG.  PAGE 

1-3.  Sections  of  Deep  Ends  of  Fundus  Glands  of  the  Cat  in  Different  Secretive 

Phases, ...  26 

4.  Plaster  Casts  of  Duodenum  of  Infant  and  Adult,      .    .    .    .  • 39 

5.  Hemmeter's  Apparatus  for  Obtaining  Intestinal  Contents, 56 

6.  Pressure  Bottles  for  Distending  the  Intragastric  Bag  during  Duodenal  Intuba- 

tion,           57 

7.  Intragastric  Tissue  Rubber  Bag,  with  Three  Distinct  Parts, 84 

8.  Location  of  the  Stomach — Dorsal  View  {^Colored), 102 

9.  Location  of  the  Stomach — Anterior  View  {^Colored), 103 

10.  Normal  Percussion  Limits  of  the  Adult  Stomach, I05 

11.  The  Electrodiaphane, 107 


XVm  LIST   OF   ILLUSTRATIONS. 

FIG.  PAGE 

12.  Hemmeter's  Double- current  Stomach  Lavage  Tube, 119 

13.  Illustrating  the  Principle  of  Siphonage, I20 

14.  Bulb  Used  for  the  Aspiration  of  Test-meals  with  Patients  Having  Very  Relaxed 

Abdominal  Walls, 120 

15.  The  Esophageal  Tubal  Probe, 123 

16.  Stomach-pump  Used  Only  for  Rapid  Evacuations  of  Poisons, 125 

17.  Modified  Ewald  Tube,  with  Numerous  Smaller  and  Larger  Lower  Openings,  126 

18.  Oppler-Boas  Bacillus  from  Contents  of  a  Carcinomatous  Stomach, 131 

19.  Fragment  of  Mucosa  Showing  a  Normal  Condition  of  Glands, 142 

20.  Hypertrophy  and  Proliferation  of  Glandular  Elements, 144 

21.  Atrophy  and  Vacuolization  of  Glandular  Elements,  etc., 145 

22.  Strauss'  Mixing  Funnel  for  Lactic  Acid  Determinations, 171 

23.  Gastroscope, 181 

24.  Esophagoscope,  Obturator,  Esophageal  Forceps,  Esophageal  Applicator,    .    .  185 

25.  Recurrent  Gastric  Needle  Spray  or  Douche, 301 

26.  The  Intragastric  Spray, 302 

27.  Rectal  Electrode, 305 

28.  Einhorn's  Intragastric  Electrode, 305 

29.  Abdominal  Electrode, 309 

30.  Massage  of  the   Stomach  in  Dilatation  or  Gastroptosis, 311 

31.  Massage  for  Improving  Gastric  Tonicity, , 312 

32.  Massage  of  the  Stomach  and  Colon,  .    .         313 

33.  Atrophy  and  Vacuolization  of  Glandular  Elements,  etc., 453 

34.  Connective-tissue  Hyperplasia  Separating  Remnants  of  Glands  Which  Show 

a  Small  Nucleus  Surrounded  by  a  Thin  Shell  of  Protoplasm, 473 

35.  Detachment    of    Remnants    of    Secretory    Cells    Containing    Vacuoles    from 

Lumen  of  Peptic  Duct, 474 

36.  Cancerous  Invasion  of  the  Glandular  Layer.     A  Portion  of  the  Mucous  Coat,  5^9 

37.  Cancerous  Infiltration  of  the  Muscularis.      Section  of  a  Portion  of  the  Muscular 

Coat  of  the  Stomach, 530 

38.  A  Portion  of  an  Area  in  the    Submucosa,  Largely  Composed   of   Groups  of 

Cancer  Cells, 531 

39.  Section  of  Tissue  Near  the  Base  of  a  Carcinomatous  Ulcer,  Showing  Micro- 

organisms (^Colored), 532 

40.  Diagrammatic  Illustration  of  the  Mechanism  Effecting  Vertical  Position  of  the 

Stomach, 627 

41.  Dilation  of  the  Stomach, 637 


TABLE  OF  CONTENTS, 


PART  FIRST. 


ANATOMY   AND   PHYSIOLOGY   OF   THE  DIGESTIVE  ORGANS.— 
METHODS  AND  TECHNICS  OF  DIAGNOSIS. 


CHAPTER  I.  PAGE 

Anatomy  of  the  Stomach, 17-24 

Muscular  Layer. — Structure  of  the  Mucous  Membrane. — Three  Kinds 
of  Cells  of  the  Peptic  Glands. 

CHAPTER  II. 

Histology  of  the  Stomach, 24-31 

Mucosa. — Vessels  and  Nerves. 

CHAPTER   III. 

The  Small  Intestine, 31-41 

Structure.  —  Valvulse  Conniventes.  —  Villi.  —  Lacteals.  —  Glands.  — 
Blood-vessels. — Lymph-vessels. — Relations  of  the  Duodenum. — Jeju- 
num and  Ileum. 

CHAPTER   IV. 

Physiology  of  Digestion, 41-48 

Food"  Substances. — Caloric  Values. — Ptyalin  Digestion. — Digestion  of 
Starches. — Gastric  Juice. 

CHAPTER   V. 

Pepsinogen  and  Pepsin. — Rennin  Zymogen  and  Rennin. — 
Fat  Splitting  Ferments  of  the  Stomach. — Intes- 
tinal Digestion. — Duodenal  Intubation,    ....         49-62 

Rennin,  Chymosin,  or  Pexin. — Physiology  of  Intestinal  Digestion. — 
The  Pancreas :    Its  Secretion  and  Pancreatic  Digestion. 

CHAPTER  VI. 
The  Bile. — The  Succus  Entericus. — Intestinal  Fermen- 
tation.—  Putrefaction. — Formed   or   Organized 
Ferments, 62-68 

CHAPTER  VII. 
Effects  of  the  Action  of  the  Several  Digestive  Secre- 
tions.— Methods  for   Testing  the  Motor  Func- 
tions of  the  Stomach, 6S-75 

Qualitative  and  Quantitative  Methods  for  Testing  the  Motor  Functions 
of  the  Stomach. 

xix 


XX  TABLE   OF   CONTENTS. 

CHAPTER  VIII.  PAGK 

Methods  for  Testing  the  Gastric  Peristalsis,    ....         75-82 

CHAPTER  IX. 
Hemmeter's    Method    for   Testing   the    Gastric    Peris- 
talsis,                82-94 

Theories  Concerning  the  Movements  of  the  Ingesta. 

CHAPTER  X. 
Absorption  from  the  Stomach, 94-101 

Penzoldt's  and  Faber's,  Herschel's,  Julius  Miller's,  and  Hemmeter's 
Tests  for  Gastric  Resorption. 

CHAPTER  XL 

Methods    for    Determining    the    Location,     Size,    and 

Capacity  of  the  Stomach,       101-116 

Percussion  and  Auscultation. — Location,  Size,  and  Capacity. — Gastro- 
diaphany  of  Einhorn. — Literature. 

CHAPTER  XII. 
The  Stomach-tube  and  Technics  of  its  Introduction,  .    .     11 6-1 28 

Examination  of  Stomach  Contents. — Test-meals  :  Their  Effect  upon 
the  Amount  of  Acid  Secreted. — Literature. 

CHAPTER  XIII. 

Methods    for    Qualitative    and    Quantitative    Analysis 

of  Stomach  Contents, 12  9-1 41 

Presence  of  Bits  of  Gastric  ^lucosa.  —  Examination  of  Stomach  Con- 
tents for  Mucus,  Saliva,  Bile,  Duodenal  Secretions,  Blood,  and  Pus. — 
Tests  for  Blood  in  Stomach  Contents. — Demonstration  of  the  Presence 
of  Iron  in  Stomach  Contents  or  Vomited  Matter. — Spectroscopical  Ex- 
amination of  Stomach  Contents  for  Blood. — Examination  of  Portions 
of  Mucosa  or  Tissue  Found  in  the  Wash-water  or  Vomited  Matter. — 
Character  and  Amount  of  Undigested  Food. — Bacteria.  —  Literature. 

CHAPTER  XIV. 

The   Diagnostic    Significance    of  Fragments  of  Gastric 

Mucosa, 141-150 

Deductions  from  Fifty  Cases. 

CHAPTER  XV. 
The  Chemistry  of  Gastric  Digestion, 150-157 

Occurrence    of   Secretions   in   the    Empty   Stomach. — Stimulations  to 

Secretions  of   Gastric  Juice. — .Significance  of  Foam. — Preparation  of 

Gastric  Contents. — Quantitative  Analysis. — Methods. — Standard  or 
Normal  Solutions. — Indicators. — Titration. — Apparatus. 

CHAPTER  XVI. 

Chemical  Examination  of  Gastric  Juice, 15S-165 

Tests  for  Presence  of  Free  Acids. — Tests  for  Free  Hydrochloric  Acid. 
— The  Dimethyl-amido-azobenzol  Test. — The  Resorcin  Test. — Com- 
bined Hydrochloric  Acid. — Lactic  Acid  :  Formation,  Significance, 
Detection. — The   Phlorocrlucin-Vanillin  Test. 


TABLE   OF   CONTENTS.  XXI 

CHAPTER  XVII.  PAGE 

Quantitative  Analysis  OF  THE  Stomach  Acids, 165-173 

Topfer's  Method. — Method  of  Martius  and  Liittke. — Leo's  Method. — 
Boas'  Method.  —  Lactic  Acid  :  Quantitative  Estimation,  Boas'  Method. 
— Quantitative  Estimation  of  Fatty  Acids. — Total  Organic  Acids. 

CHAPTER  XVIII. 
Digestive  Ferments. — Products  of  Digestion. — Tests  for 

Same, 173-180 

Saliva.  —  Pepsin. — Pepsinogen.  —  Chymosin  or  Rennin  and  Rennin 
Zymogen. — Action  of  Pepsin  on  Proteids. 

CHAPTER  XIX. 

Gastroscopy, 180-186 

Description  of  the  Instrument. 


PART    SECOND. 


THERAPY   AND   MATERIA   MEDICA  OF   STOMACH   DISEASES. 


CHAPTER  I. 
The     Principles    of    Dietetic     Treatment    of    Gastric 

Diseases, 187-229 

Preparations  of  the  Foods. —  1  he  iJiet  as  Intluenced  by  the  State  of  the 
Secretion. — The  Dietetics  of  Gastric  Ulcer  and  Erosions. — The  Indica- 
tions for  Predigested  Foods:  Peptones,  Albumoses,  Dextrose,  etc. — 
Rectal  Alimentation. — The  Occurrence  of  Proteolytic  Ferments  in  the 
Colon  and  Rectal  Contents. — Preparation  of  Rectal  Enemata. — Indica- 
tions Necessitating  Rectal  Feeding. — Tables  of  Dietetics. 

CHAPTER  II. 
Dietetic  Kitchen. — Diet  Lists, 230-289 

Effects  of  Cooking  on  Food. — Indications  of  the  Palate. — Dietetical 
Cooking. — The  Use  and  Abuse  of  Rest  and  Exercise  for  the  Digestive 
Organs. — Mental  Rest. — Dietetic  Exercise. 

CHAPTER  III. 

The  Dietetics  of  Alcohol  and  Alcoholic  Beverages,  .    .     289-299 
Action  of   Alcohol  on  Pancreatic  Digestion.— Action  of  Alcohol  on 
Salivary  Digestion. — Action  of  Alcohol  on  Gastric  Peristalsis. — Effect 
on  Absorption. 

CHAPTER  IV. 

Lavage  and  the  Gastric  Douche, 299-315 

The  Gastric  Douche. — Electricity  in  the  Treatment  of  Gastric  Diseases. 
—  Hydrotherapeutic  and  Orthopedic  Methods. — Gastric  Massage. — - 
Combination  of  Massage  and  Medicated  Irrigations  of  Stomach  and 
Colon. 

CHAPTER  V. 

Mineral  Springs, 315-329 

The  Uses  and  Abuses  of  Natural  Mineral  Waters  in  Diseases  of  the 
Digestive  Organs. — Useful  Mineral  Springs  of  the  United  States,  with 
Analyses  and  Mode  of  Action. 


xxii  table;  of  contents. 

CHAPTER  VI.  PAGE 

Important  Medicinal  Agents  in  Gastric  Therapy,    .    .    .     329-348 

Hydrochloric  Acid. — The  Alkalies. — The  Bitter  Tonics  and  So-called 
Stomachic  Remedies. — Digestive  Ferments. 

CHAPTER  YII. 
Surgical  Treatment  of  Organic  Gastric  Diseases,      .    .     349-374 

Various  Forms  of  Operations  Practised  upon  the  Stomach. — The 
Fundamental  Factors  Influencing  the  Rate  of  Mortality  in  Gastric 
Operations. — Operative  Statistics. 

CHAPTER  VIII. 
Influence  of  Gastric  Diseases  upon  Other  Organs  and 

on  Metabolism, 375-401 

The  Influence  of  Diseases  of  Other  Organs  on  the  Stomach. — Literature. 

CHAPTER  IX. 

The  Blood  and  Urine  in  Stomach   Diseases, 401-414 

The  Gases  of  the  Stomach. — Urinary  Changes  in  Stomach  Diseases. 


PART   THIRD. 


THE  GASTRIC  CLINIC. 


CHAPTER  I. 

Acute  Gastritis, 415-444 

Simple  Acute  Gastritis. — Phlegmonous  or  Purulent  Gastritis. — Suppur- 
ative Inflammation  of  the  Gastric  Mucosa. — Abscess  of  the  Stomach. 
— Infectious  Gastritis. — Gastritis  Mycotica  or  Parasitaria. — Gastritis 
Diphtherica  and  Crouposa. — Toxic  Gastritis. — Gastritis  Venenata. 

CHAPTER  II. 

Chronic  Gastritis, 444-486 

Literature. 

CHAPTER  III. 

Ulcer  of  the  Stomach, 4S6-527 

Ulcus  Ventriculi,  Pepticum,  Rotundum,  Perforans,  Rodens,  Corrosivum, 
e  Digestione. — Literature. 

CHAPTER  IV. 

Malignant  Tumors  of  the  Stomach, 527-589 

Carcinomata. — Sarcomata. — Literature. — Table  of  Differential  Diag- 
nosis. 

CHAPTER  V. 

Stomach  Diseases  Caused  by  Infectious  Granulomata,  .     590-606 

Tuberculosis  of  the  Stomach.— Syphilis  of  the  Stomach.— Literature. 


TABLE    OF    CONTENTS.  XXiii 

CHAPTER  VI.  PAGH 

Benign  Tumors  of  the  Stomach, 606-623 

Myomata. — Fibromata.  — Lipomata. — Polypi. — Myxomata.  — Papillo- 
mata. — Lj'mphadenomata. — Pedunculate  Tumors. — Foreijjn  Bodies. — 
Gastroliths. — Hypertrophic  Stenosis  of  the  Pylorus.  —  Literature. 

CHAPTER  VH. 
Motor  Insufficiency, 623-680 

Gastric  Atony  or  Myasthenia. — Gastrectasis  (Dilation  of  the  Stom- 
ach).— Obstruction  of  the  Orifices. — Literature. 

CHAPTER  VHL 
Hemorrhage  from  the  Stomach  (Gastrorrhagia),  .    .    .     680-693 

CHAPTER  IX. 
Enteroptosis — Gastroptosis, 693-730 

History  and  Pathogenesis  of  Enteroptosis. — Observation  on  Gastrop- 
tosis.— Observation  on  Dislocation  of  the  Colon. — Observation  on  Dis- 
location of  the  Liver. — Literature. 

CHAPTER  X. 

Neuroses  of  the  Stomach,     . 731-790 

General  Considerations. —  Cardiospasm. — Pyloric  Spasm. —  Gastro- 
spasra.  — Gastric  Hyperperistalsis. —  Nervous  Eructation. —  Nervous, 
Habitual,  or  Reflex  Vomiting. — Insufficiency  or  Incontinence  of  the 
Cardia.  —  Rumination,  or  Merycism. — Insufficiency  or  Incontinence  of 
the  Pylorus. — Atony  of  the  Stomach. — Literature.  * 

chapter  XI. 
Sensory  Neuroses, 791-813 

Hyperesthesia. — Gastralgia.— Bulimia,  or  Hyperorexia. — Acoria. — 
Nervous  Anorexia. 

chapter  XII. 

Neuroses  of  Secretion, 813-845 

Hyperchylia. — Periodic  Atypical  Flow  of  Gastric  Juice. — Chronic 
Continuous  Flow  of  Gastric  Juice. — Literature. — Subacidity. 

CHAPTER  XIII. 
Achylia  Gastrica, 846-860 

CHAPTER  XIV. 
Nervous    Dyspepsia    (Leube). — Neurasthenia    Gastrica 

(Ewald), 860-872 

Heterochylia. 


List  of  Authors, 875 

List  of  Subjects, '  885 


Diseases  of  the  Stomach. 


PART    FIRST. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  DIGESTIVE 

ORGANS.— METHODS  AND  TECHNICS 

OF   DIAGNOSIS. 


CHAPTER  I. 
ANATOMY  OF  THE  STOMACH. 

The  organic  diseases  which  affect  the  human  stomach  produce 
decided  and  characteristic  changes  in  its  structure.  For  the  proper 
comprehension  of  these,  a  brief  outHne  of  the  normal  anatomy  and 
histology  is  indispensable.  Even  a  short  reference  to  the  embr}''- 
ology  of  the  human  stomach  will  have  to  be  made,  but  this  w411  be 
limited  to  the  two  diseases — viz.,  enteroptosis  and  gastroptosis,  the 
pathogenesis  of  which  will  become  more  intelligible  by  a  review  of 
the  fetal  development  of  this  organ. 

Many  valuable  contributions  to  the  subject  of  the  macroscopical 
and  microscopical  anatomy  of  the  stomach  have  been  made  during 
recent  years.  In  the  subjoined  brief  synopsis  we  have  availed 
ourselves  of  the  valuable  researches  of  F.  Mall,  and  of  the  works 
quoted  by  him  in  the  bibliography  given  in  his  article  in  the  "Johns 
Hopkins  Hospital  Reports,"  volume  i.  The  comprehensive  works 
of  Oppel,  Spalteholz,  and  others  which  have  appeared  during  1896- 
'99,  have  also  been  consulted. 

The  stomach  is  the  dilated,  sac-like  portion  of  the  digestive  tract, 
between  the  esophagus  and  the  small  intestine.  One  can  distinguish 
a  lower  convex  arch,  the  greater  curvature,  which  is  directed  toward 
the  left  and  downward;  and  an  upper  concave  arch,  the  lesser  cur^^a- 
ture,  which  is  directed  toward  the  right  and  upward.  The  broad 
2  17  • 


1 8  ANATOMY   OF   THE    STOMACH. 

left  end  of  the  greater  cun,'ature  is  called  the  fundus,  the  size  of 
which  varies  according  to  age.  Between  the  fundus  and  the  lesser 
curvature  is  situated  the  cardia,  being  the  continuation  and  funnel- 
shaped  expansion  of  the  esophagus.  While  it  is  not  marked  on 
the  outside  of  the  organ,  there  is  a  distinct  limiting  line  internally 
on  the  mucous  membrane,  which  is  caused  by  a  change  in  the  struc- 
ture of  the  epithelial  lining.  This  zigzag  line  separates  the  cardia 
from  the  esophagus.  At  this  point  the  arrangement  of  the  muscular 
fibers  and  veins  is  also  different  from  that  in  the  esophagus. 

The  location  of  the  cardia  in  the  adult  is  at  the  twelfth  dorsal 
vertebra.  At  about  the  height  of  the  bifurcation  of  the  bronchi, 
the  spiral  cur\dng  of  the  esophagus  around  the  aorta  begins.  By 
executing  this  curve,  the  convexity  of  which  is  toward  the  right, 
the  esophagus  gets  to  the  left  side  of  the  aorta,  and  passes  through 
the  diaphragm  in  the  foramen  oesophageum,  near  the  spinal  column. 

The  stomach  becomes  narrower  from  the  fundus  toward  the 
pylorus.  Near  the  pylorus  there  is  a  constriction,  caused  by  a 
ring-like  formation  of  muscular  tissue,  which  corresponds  to  the 
pyloric  valve.  The  muscular  tissue  is  covered  internally  by  the 
gastric  mucous  membrane,  the  latter  forming  the  pyloric  valve,  the 
opening  of  which  is  of  var\4ng  diameter.  The  part  of  the  stomach 
in  advance  of  the  pylorus  is  called  the  pyloric  antrum,  and  is  fre- 
quently separated  from  the  greater  curvatm-e  by  an  indentation  or 
depression.  This  antrum  may  be  elongated  so  as  to  assume  re- 
semblance to  the  intestine;  this  is  more  frequently  the  case  in  the 
female. 

On  the  anterior  and  posterior  walls  of  the  stomach,  running  along 
between  the  muscular  and  serous  coats  of  the  organ,  are  two  band- 
like stripes,  consisting  of  elastic,  smooth,  muscular  fibers, — the 
p3doric  ligaments. 

The  size  of  the  stomach  depends  upon  age,  sex,  and  individuality, 
and  upon  the  degree  of  its  distention.  The  long  axis  varies  from 
25  to  35  cm.  The  greatest  vertical  measurement,  at  the  cardia, 
is  15  cm.,  and  the  greatest  straight  diameter  is  from  11  to  12  cm.; 
the  smallest,  at  the  pyloric  antrum,  is  from  3  to  4  cm.  In  the  female 
it  is  generally  smaller  and  more  slender. 

The  capacity  varies  considerably:  Ewald  considers  from  1600 
to  1700  c.c.  to  be  the  normal  limit.  Three-fourths  of  the  stomach 
belongs  to  the  left  half  of  the  body  and  one-fourth  to  the  right  half. 
The  cardia  is  located  behind  the  median  edges  of  the  fifth  and  sixth 


DIAPHRAGM — PANCREAS.  1 9 

ribs.  The  fundus,  the  largest  part  of  the  body  of  the  organ,  is  in 
the  left  hypochondrium ;  the  rest,  with  the  pyloric  part,  is  in  the 
epigastrium.  The  pylorus  lies  in  the  right  half  of  the  body,  but 
occasionally  changes  to  the  middle  line  at  the  level  of  the  seventh 
and  eighth  ribs,  in  a  Hne  with  the  ensiform  cartilage.  The  lesser 
curvature  runs  along  to  the  left,  and  near  the  spinal  column.  The 
vaulting  dome  of  the  fundus,  which  applies  itself  to  the  concavity 
of  the  diaphragm,  is  the  highest  point.  The  deepest  point  of  the 
stomach  is  in  the  greater  curvature,  in  the  inferior  half  of  an  imagi- 
nary straight  line  connecting  the  ensiform  cartilage  with  the  umbih- 
cus.  Both  the  highest  and  lowest  parts  of  the  stomach  are  moved 
about  according  to  the  level  of  the  diaphragm  and  the  distention  of 
the  stomach.  In  an  empty  condition,  the  stomach  is  withdrawn 
into  the  upper  portion  of  the  abdomen;  but  when  filled,  it  distends 
in  all  directions,  but  mostly  in  the  direction  of  its  long  axis,  from 
the  left  above,  downward,  and  to  the  right.  In  a  state  of  moderate 
distention  about  forty  centimeters  of  its  anterior  wall  come  in  contact 
with  the  inner  surface  of  the  anterior  abdominal  wall. 

The  diaphragm  covers  the  fundus  and  the  largest  part  of  the  left 
segment,  while  the  left  lobe  of  the  liver,  up  to  the  sulcus  interlobu- 
laris,  covers  the  smallest  part — that  is,  the  lesser  curvature  and 
the  pyloric  portion.  From  this  fact  arises  the  difficulty  in  palpating 
tumors  in  the  latter  places,  which  is  impossible  except  when  gastrop- 
tosis,  or  descent  of  the  stomach,  moves  it  away  from  the  liver. 
In  the  state  of  expansion  or  dilatation,  the  stomach  moves  out  from 
behind  the  liver ;  but  the  lesser  curvature  can  not  change  its  location 
to  any  considerable  extent,  and  the  change  of  location  of  the  whole 
stomach  caused  by  filling  is  produced  almost  exclusively  by  an 
extension  of  the  greater  curvature. 

The  pancreas  extends  along  the  posterior  wall  of  the  stomach. 
At  the  upper  edge  of  the  pancreas  are  the  splenic  artery  and  vein. 
The  transverse  colon  runs  along  the  greater  curvature,  and  its  left 
flexure  fills  the  remaining  space  in  the  left  hypochondrium.  The 
location  of  the  stomach  is  fixed  by  a  ligamentous  attachment  of  the 
cardia,  by  the  pylorus,  and  also  by  a  number  of  suspensory  liga- 
ments, which  are  all  formations  of  the  peritoneum.  Some  authors 
say  that  the  stomach  is  supported  in  this  position  by  intra-abdominal 
pressure.  The  experiments  of  Moritz,  of  Munich,  and  the  author 
have  proved  that  intra-abdominal  pressure  adds  nothing  to  the 
support  of  the  stomach.     The  gastrophrenic  ligament,  which  toward 


20  ANATOMY    OF    THE)    STOMACH. 

the  right  passes  into  the  lesser  omentum,  and  toward  the  left  extends 
into  the  phrenosplenic  ligament,  surrounds  and  embraces  the  cardia. 
This  portion  is  lower  than  the  fundus,  its  situation  corresponding 
to  the  upper  end  of  the  sixth  and  seventh  costal  cartilages,  or  to 
the  level  of  the  ninth  thoracic  vertebra.  This  part  of  the  stomach 
is  therefore  moved  to  the  left  of  the  middle  line,  and  next  to  the 
spinal  column,  at  about  the  level  of  the  twelfth  thoracic  and  first 
lumbar  vertebrae ;  here  it  is  fixed  to  the  lumbar  part  of  the  diaphragm. 

The  greater  omentum  arises  from  the  large  curvature.  The 
posterior  fold  of  this  omentum  forms  the  transverse  mesocolon. 
This  is  the  reason  why  changes  of  location  in  the  greater  omentum 
(hernia  and  inflammatory  adhesions)  can  produce  traction  upon  the 
stomach.  As  the  stomach  is  really  attached  only  at  the  cardia,  and 
the  pylorus  is  adherent  to  the  posterior  abdominal  wall,  together  with 
the  descending  portion  of  the  duodenum,  the  organ  is  capable  of 
being  moved  about,  not  so  much  in  its  entirety  as  in  its  parts  (the 
great  curvature,  for  instance).  The  stomach  has  a  complete  peri- 
toneal covering  which  consists  of  an  anterior  and  a  posterior  layer, 
uniting  at  the  two  curvatures  of  the  stomach  to  form  the  lesser  and 
the  greater  omentum;  between  these  two  layers  space  is  left  for 
the  blood-  and  lymph-vessels  of  the  stomach. 

Muscular  Layer. — The  muscular  stratum  contains  three  kinds 
of  fibers — longitudinal,  transverse,  and  oblique.  The  longitudinal 
layer  of  muscular  fibers — a  continuation  of  those  of  the  esophagus — 
presents  a  denser  arrangement  at  the  lesser  curvature  than  at  the 
greater,  and  forms  the  ligamenta  pylorica  at  the  pyloric  part,  which 
are  bands  of  muscular  fibers  expanded  and  broadened  out, — not 
ligaments  in  the  real  sense  of  the  word. 

The  circular  layer  of  muscular  fibers  is  placed  internally  to  the 
longitudinal  layer,  the  fibers  of  which  it  crosses  at  right  angles. 
The  circular  fibers  run  around  the  stomach  in  a  ring  or  belt-like 
manner;  at  the  pylorus  they  form  a  local  thickening  of  the  muscle 
rings — the  pyloric  sphincter.  A  fold  of  the  mucosa  to  the  innermost 
side  of  this  sphincter  constitutes  the  pyloric  valve.  The  longi- 
tudinal fibers  also  have  a  part  in  the  formation  of  the  sphincter, 
for  while  the  superficial  layer  of  longitudinal  fibers  passes  on  over 
the  pyloric  sphincter  into  the  duodenum,  the  deeper  longitudinal 
fibers  enter  the  pyloric  valve,  encircling  and  grasping  the  circular 
fibers  in  a  loop-like  manner  (dilator  pylori — Riidinger).  The  cardia 
has  no  special  sphincter,  but  the  oblique  fibers  cross  and  decussate 


MUCOUS   MEMBRANE.  21 

at  the  periphery  of  this  portion.  The  sphincter  pylori  is  contracted 
during  digestion,  but  gas  and  liquids  can  readily  escape  through  the 
cardia.  The  oblique  fibers  are  limited  chiefly  to  the  cardiac  end  of 
the  stomach,  where  they  are  disposed  as  a  thick,  uniform  layer, 
some  passing  obliquely  from  left  to  right,  others  from  right  to  left, 
around  the  cardiac  orifice.  The  submucosa,  or  cellular  coat  of  the 
stomach,  consists  of  a  loose,  filamentous,  areolar  tissue,  and  loosely 
binds  the  mucosa  to  the  muscular  layers. 

The  most  important  and  interesting  layer  is  the  mucosa,  or  mucous 
membrane  proper  of  the  stomach.  It  is  a  thick  layer  with  a  smooth, 
soft,  velvety  surface.  During  infancy  and  immediately  after  death  it 
is  of  a  pinkish  tinge,  but  in  adult  life  and  in  old  age  it  becomes  of  a 
pale  straw  or  ash-gray  color.  At  the  pylorus  it  is  much  thicker 
than  at  the  cardia.  During  the  contracted  state  of  the  organ  it  is 
thrown  into  numerous  plaits  or  rugae,  which,  for  the  most  part, 
have  a  longitudinal  direction,  and  are  most  marked  toward  the  lesser 
end  of  the  stomach  and  along  the  greater  curvature ;  these  folds  are 
entirely  obliterated  when  the  organ  becomes  distended. 

Structure  of  the  Mucous  Membrane. — When  examined  with 
a  lens,  the  inner  surface  of  the  mucous  membrane  presents  a  peculiar 
honeycomb  appearance,  from  being  covered  with  small,  shallow 
depressions,  or  alveoli,  of  a  polygonal  or  hexagonal  form,  which 
vary  from  y^^  to  ^^-^  of  an  inch  in  diameter,  and  are  separated  by 
slight  ridges.  In  the  bottom  of  the  alveoli  are  seen  the  orifices  of 
minute  tubes, — the  gastric  follicles,— which  are  situated  perpen- 
dicularly side  by  side  in  the  entire  substance  of  the  mucous  mem- 
brane. They  are  short  and  of  a  simple  tubular  character  toward 
the  cardia,  but  at  the  pyloric  end  they  are  longer,  more  thickly 
set,  convoluted,  and  terminate  in  dilated  saccular  extremities,  or 
are  subdivided  into  from  two  to  sixteen  tubular  branches. 

Watney  has  pointed  out  that  these  convoluted  or  coiled  tubes 
form  the  transition  from  the  simple  tubular  follicles  to  the  convo- 
luted glands  of  Brunner,  which  lie  immediately  below  the  pylorus. 
Some  histologists  speak  of  a  homogeneous  basement  membrane, 
formed  by  the  connective-tissue  framework,  lined  upon  its  free  sur- 
face by  a  layer  of  cells,  which  differ  in  their  character  in  different 
parts  of  the  stomach.  The  author  could  never  confirm  the  existence 
of  such  a  basement  membrane.  Toward  the  pylorus  the  tubes 
are  lined  throughout  by  columnar  or  cuboidal  epithelium;  they  are 
termed  the  mucous  glands,  and  are  supposed  to  secrete  the  gastric 


22  ANATOMY    OF   THE    STOMACH. 

mucus.  In  other  parts  of  the  organ  the  deep  part  of  each  tube  is 
filled  with  nucleated  cells,  the  upper  fourth  of  the  tube  being  lined 
by  columnar  epithelium :  these  are  called  the  peptic  glands,  and  are 
the  source  of  the  gastric  juice. 

Simple  foUicles  are  found  in  greater  or  less  numbers  over  the 
entire  surface  of  the  mucous  membrane;  they  are  most  numerous 
near  the  pyloric  end  of  the  stomach,  and  are  especially  distinct  in 
early  life.  The  epithelium  lining  of  the  mucous  membrane  of  the 
stomach  and  its  alveoli  is  of  the  columnar  variety. 

Usually  four  to  sixteen  gland  openings  are  found  at  the  base  of 
each  follicle.  According  to  Sappey,  there  are  5,000,000  of  these 
glands  in  the  organ,  for  which  reason  the  gastric  mucosa  may  justly 
be  considered  a  continuous  gland  spread  out  upon  a  fiat  sm^face 
(Hyrtl  and  Luschka).  The  gland  tubules  are  as  long  as  the  entire 
thickness  of  the  mucosa,  and  their  sac-like  and  branched  bases 
extend  into  the  muscularis  mucosae,  the  contraction  of  which  assists 
in  the  evacuation  of  the  tubules  during  digestion.  The  ends  of  the 
tubules  extending  into  the  muscular  layer  are  usually  branched. 

Three  Kinds  of  Cells  of  the  Peptic  Glands. — First,  the  cyHn- 
drical  cells  of  the  gland  duct  and  pit,  lining  one-fourth  to  one-third 
of  the  distance  from  the  surface  of  the  mucous  membrane  downward. 
They  are  a  continuation  of  the  cylindrical  epithelium  of  the  general 
internal  surface  of  the  gastric  mucous  membrane,  apparently  secret- 
ing mucus  only.  Secondly,  the  lightly  colored  pyramidal  or  cuboidal 
cells,  with  a  granular  protoplasm  and  spherical  nucleus.  These  cells 
do  not  stain  with  anilin,  and  were  termed  adelomorphous  cells  by 
Rollet  because  they  show  no  cell  contours  in  the  fresh  state.  Rosen- 
heim states  that  they  are  almost  clear  and  transparent  during  fasting, 
and  become  cloudy  and  granular  during  digestion.  Heidenhain 
designated  them  as  the  chief  or  central  cells,  and  they  were  held  by 
him  to  be  the  sources  of  the  ferments  pepsinogen  and  rennin  zymogen. 
These  chief  or  central  cells  touch  the  lumen  of  the  duct  more  ex- 
tensively than  the  following  variety.  The  third  kind  of  peptic  cells 
are  known  as  the  border,  parietal,  or  oxyntic  cells;  they  rest  upon 
the  connective-tissue  framework  with  much  broader  bases  than  the 
chief  or  central  cells.  For  this  very  reason  they  participate  to  a  less 
degree  in  the  limitation  of  the  lumen  of  the  duct.  They  are  generally 
round  or  triangular,  finely  granular,  and  stain  intensely  with  anilin, 
and  were  designated  by  Rollet  as  delomorphous  cells.  Heidenhain 
supposes  them  to  be  the  sources  of  hydrochloric  acid.     If  we  assume, 


PEPTIC   CELLS.  23 

for  the  sake  of  locating  these  various  cells,  a  division  of  the  tubule 
into  four  sections,  beginning  at  the  portion  nearest  the  submucosa, 
we  shall  have  (a)  the  fundus  of  the  gland  tubule ;  then  (5)  the  outer 
secretory  portion;  (c)  the  inner  secretory  portion;  and,  opening  on 
the  inner  surface  of  the  mucosa,  (d)  the  alveolus  ("Vorraum"). 
Then,  one  finds  the  border,  parietal,  oxyntic,  delomorphous,  or  anilin 
cells  most  numerous  in  the  outer  secreting  portion,  and  becoming 
scarce  in  the  fundus  or  end  portion.  A  fourth  kind  of  cell,  occurring 
at  rare  intervals,  is  known  as  Nussbaum's  cell;  its  significance  is 
unknown. 

Heidenhain  asserted  that  there  were  no  border  cells  in  the  fundus 
at  all;  but  this  has  been  denied  by  Stohr,  Kupffer,  and  Boas.  The 
size  of  border  or  acid  cells  depends  upon  the  stage  of  digestion; 
as  this  function  proceeds,  the  border  cells  increase,  and  diminish 
again  at  the  end  of  digestion.  The  chief,  central,  or  ferment  cells 
enlarge  also,  and  become  darker  during  digestion.  In  a  fasting 
state  the  chief  cells  are  largely  in  excess.  Heidenhain's  conclusions, 
that  the  chief  or  central  cells  are  producers  of  the  digestive  ferments, 
and  that  the  border  or  anilin-staining  cells  produce  the  hydrochloric 
acid,  have  been  confirmed  by  a  number  of  other  observers  (Griitzner, 
von  Swiezicki,  and,  recently,  Sehrwald  and  Mall). 

It  is  known  that  the  glandular  tubules  of  the  pyloric  region  con- 
tain only  chief  or  central  cells  (producing  ferments  only,  and  no 
acid),  while  the  gland  tubules  of  the  fundus  contain  both  central 
cells  and  also  border  or  acid  cells.  Heidenhain  succeeded  in  re- 
moving the  pyloric  portion  of  the  stomach  entirely  in  a  number 
of  dogs,  and  uniting  the  organ  with  the  external  abdominal  wall. 
In  other  dogs  he  removed  tlie  fundus  entirely,  leaving  the  pyloric 
portion  intact,  and  succeeded  in  making  this  altered  stomach  without 
a  fundus  unite  with  the  external  abdominal  wall. 

He,  therefore,  had  two  kinds  of  operated  animals  with  stomachs 
opening  on  the  abdomen.  After  this,  it  was  found  that  animals  in 
which  the  pyloric  region  was  excised  furnished  a  juice  that  con- 
tained both  acid  and  pepsin;  these  are  therefore  produced  by  the 
glands  of  the  fundus  which  contain  both  varieties  of  secretory  cells. 
In  the  animals  that  had  been  deprived  of  the  fundus  by  excision, 
however,  the  only  secretory  surface  that  was  left  being  the  pyloric 
region,  it  was  found  that  an  alkaline  juice  was  secreted  containing 
only  ferments.  That  this  juice  did  contain  pepsin  was  proved  by 
its  power  of  digesting  fibrin  when  hydrochloric  acid  was  added  to  it. 


24  HISTOLOGY   OF   THE    STOMACH. 

Now,  as  the  gland  tubules  of  the  pylorus  contain  only  chief  or 
central  cells,  which  do  not  stain  with  aniHn,  the  conclusion  seems 
justifiable  that  the  chief  cells  secrete  only  ferments,  and  that  there- 
fore the  border  or  aniHn- staining  cells  must  secrete  the  hydrochloric 
acid. 

It  has  been  found  that  the  border  or  acid  cells — called  also  the 
oxyntic  cells — are  in  communication  with  the  central  canal  of  the 
gland  tubule  by  tiny  canahculi — extensions  from  the  central  lumen 
of  the  gland  to,  or  into,  the  oxyntic  or  acid  cells.  These  canahcuH 
were  brought  out  with  the  silver  stain  by  Golgi. 


CHAPTER  II. 
HISTOLOGY  OF  THE  STOMACH. 

R.  R.  Bensle}^,  B.A.,  M.B.,  has  published  a  very  interesting  paper 
on  the  "Histology  and  Phj^siology  of  the  Gastric  Glands,"  in  the 
"Proceedings  of  the  Canadian  Institute,"  1896.  The  work  was 
done  in  the  biological  laboratory  of  the  University  of  Toronto. 
Mr.  Bensley  was  kind  enough  to  present  us  with  four  sketches  illus- 
trating the  various  phases  of  secretion  in  the  gland  cells  of  the  deep 
ends  of  the  fundus  glands  of  the  cat's  stomach.  We  consider  his 
results  a  valuable  addition  to  the  work  of  Heidenhain,  Ebstein, 
Tangley,  Sewall,  and  others.  We  have,  by  repeating  his  methods, 
assured  ourselves  that  with  staining  as  used  by  him,  it  is  possible 
to  recognize  the  precursory  stages  of  the  ferments  within  the  struc- 
ture of  the  cells.  We  submit  the  drawings,  with  explanatory  text. 
The  following  are  his  conclusions: 

"i.  During  digestion,  a  substance  similar  in  chemical  properties 
to  the  chromatin  of  the  nucleus  makes  its  appearance  in  the  outer 
clear  zone  of  the  chief  cells  of  the  fundus  glands.  This  substance, 
which  may  be  called  prozymogen,  stains  deeply  and  readily  in  hema- 
toxvlin,  and  presents  a  characteristic  fibrillated  appearance.  During 
rest  this  prozymogen  is  used  up  in  some  way,  giving  rise  to  zj-mogen 
granules. 

"2.  The  chief  cells  of  the  neck  of  the  glands  do  not  contain  at 
any  period  of  digestion  either  zymogen  or  prozymogen,   but  are 


MUCOSA.  25 

engaged  in  the  formation  of  a  mucinoid  secretion,  which  has  a  power- 
ful elective  affinity  for  induUn  and  Bordeaux  red,  and  stains  meta- 
chromatically  in  thionin. 

"3.  The  pyloric  gland  cells,  likewise,  form  neither  zymogen  nor 
prozymogen,  and  are  similar  in  structure,  in  staining  properties,  and 
in  the  nature  of  their  secretion,  to  the  cells  of  the  neck  of  the  fundus 
gland. 

"4.  The  cells  of  the  pyloric  glands  and  of  the  neck  of  the  fundus 
glands  pass,  by  gradual  transition,  into  the  mucous  cells  of  the  sur- 
face, to  which  they  are  obviously  closely  allied." 

From  Mall's  article  on  the  anatomy  of  the  stomach  ("Johns 
Hopkins  Hospital  Reports,"  vol.  i)  we  have  quoted  the  following 
graphic  description: 

Mucosa. — That  more  than  one  kind  of  gland  is  present  in  the 
stomach  has  been  repeatedly  noticed  (Wassman,  Frerichs,  Brinton, 
Leydig,  KoUiker),  but  a  more  careful  study  of  them  was  delayed 
until  1870  (Heidenhain,  Rollet). 

There  are  two  kinds  of  glands  present  in  the  dog's  stomach — 
the  pyloric  and  the  peptic.  The  peptic,  in  turn,  are  formed  in  great 
part  of  two  kinds  of  cells — the  border  or  oxyntic  and  the  central 
or  ferment  cells. 

A  study  of  descriptions  of  Mall  and  Oppel  shows  that  in  the  pyloric 
region  the  necks  of  the  glands  are  the  longest  (0.68  mm.),  and  that 
they  diminish  in  length  throughout  the  middle  zone  (0.25  mm.), 
until  the  cardiac .  portion  is  reached.  In  the  pyloric  portion,  where 
the  necks  of  the  glands  are  the  longest,  many  gland  tubes  empty 
into  one  outlet;  in  the  middle  zone  there  are  less,  in  rough  about 
nine,  into  each  gland  mouth ;  while  in  the  cardiac  portion  each  gland 
has  a  special  opening — in  other  words,  there  are  no  gland  necks. 
In  the  pyloric  portion  the  glands  are  composed  wholly  of  central 
cells.  In  the  central  zone  there  are  many  border  cells,  the  propor- 
tion to  the  central  cells  being  as  described  by  Heidenhain  and  his 
pupils.  Throughout  the  fundus  are  but  few  border  cells,  while 
around  the  esophagus  there  is  a  small  zone  in  which  there  are  many 
border  cells. 

According  to  Mall,  about  1 600  gland  •  tubes  open  within  each 
square  centimeter  of  mucous  membrane  in  the  pyloric  portion,  in 
the  middle  zone  2500,  and  in  the  fundus  4900.  For  an  average 
stomach  there  is  an  area  of  about  28  square  cm.  in  the  pylorus,  108 
in  the  middle  zone,  and  120  in  the  cardiac  portion,  or  these  surfaces 


26 


HISTOLOGY   OF    THE    STOMACH. 


are  to  each  other  as  7  :  27  :  30.  The  estimation  carried  further 
gives  somewhat  over  1,000,000  gland  openings  in  the  stomach. 
On  the  other  hand,  if  the  bhnd  tubes  opposite  the  muscularis  mu- 


b 


-F 


Fig.  I. 


Fig.  2. 


r^  ^^U 


Fig.  3. 

Sections  of  Deep  Ends  of  Fundus  Glands  of  the  Cat  in  Different  Secretive  Phases. 

X   iooo.~-{Be)is/ey.) 

Fig.  I. — From  a  fasting  stomach.  The  chief  cells  are  filled  with  large  zymogen  granules; 
nuclei  near  the  outer  ends  of  cells.     Gentian-violet  preparation.     6.  Border  cells. 

Fig.  2. — Six  hours  after  an  abundant  meal  of  raw  flesh.  The  chief  cells  exhibit  two  zones, -the 
inner  occupied  by  large  zymogen  granules,  the  outer  by  a  deeply  staining,  obscurely  fibrillar 
element,  prozymogen ;  the  nuclei  lie  at  the  junction  of  the  two  zones,  b.  Border  cells,  pr.  Pro- 
zymogen.  c.  Mucin  secreting  cell,  similar  to  those  found  in  the  neck  of  the  gland.  Gentian- 
violet  preparation. 

Fig.  3. — Twelve  hours  after  feeding  with  sponge  soaked  in  fat.  Preparation  stained  in  hema- 
toxylin exhibits  a  deeply  stained  outer  zone  filled  with  prozymogen,  and  a  clear  inner  zone  from 
which  the  granules  have  disappeared  in  course  of  preparation.  The  nuclei  are  now  much  nearer 
to  the  lumen.     5.  Border  cells,    /r.  Prozymogen. 


cosse  are  estimated,  the  number  exceeds  16,500,000.  In  other 
words,  each  gland  neck  subdivides  sixteen  times,  on  an  average, 
before  the  muscularis  mucosae  is  reached.     It  may  be  interesting 


MUCOSA.  27 

to  note  that  for  each  gland  opening  in  the  stomach  we  have  one 
villus  in  the  intestine,  and  for  each  subdivision  there  is  one  Lieber- 
kiihn's  crypt. 

The  observations  quoted,  as  well  as  those  of  others,  apparentl}^ 
do  not  confirm  Heidenhain's  statement — i.  e.,  that  "wherever  we 
have  central  cells  we  have  pepsin."  Yet  it  seems  true  that  the 
degree  of  acidity  is  in  proportion  to  the  number  of  border  cells  pres- 
ent in  any  portion  of  the  stomach,  and  that  there  are  portions  of 
the  stomach  which  do  not  contain  border  cells,  but  yield  pepsin. 
In  general,  the  formation  of  pepsin  is  most  marked  in  those  portions 
of  the  stomach  which  produce  most  acid;  and  this  ought  to  be  the 
case,  for  acid  favors  the  formation  of  pepsin  from  pepsinogen  (Pod- 
wyssozki,  Langley,  and  Edkins),  and  the  pepsin  seems  more  or  less 
combined  with  acid  (Schiff,  Richet).  We  must,  therefore,  conclude 
with  Heidenhain  that  the  border  cells  play  a  most  important  part 
in  the  formation  of  acid.  Between  the  glands  He  the  blood-vessels, 
lymphatics,  some  round  cells,  and  the  reticulum.  In  those  portions 
of  the  stomach  in  which  there  is  a  "neck  zone,"  there  is  a  distinct 
layer  of  reticulum  fibrils.  In  this  layer  peculiar  spindle  cells  are 
frequently  seen  which  surround  the  gland  openings  and  appear  much 
like  the  subepithehal  cells  in  the  villi  of  the  intestine.  Under  no 
condition  could  a  basement  membrane  be  isolated,  nor  does  Mall 
believe  it  exists,  but  instead  there  is  a  most  beautiful  network  of  the 
reticulum. 

"Conclusions. — From  a  histological  standpoint  the  mucous 
membrane  of  the  stomach  may  be  divided  into  three  zones — the 
pyloric,  with  no  border  cells;  the  middle,  with  many  border  cells; 
and  the  fundus,  with  but  few  border  cells. 

' '  Digestion  of  the  different  portions  of  the  mucous  membrane  with 
weak  HCl  shows  that  the  middle  zone  digests  most  easily,  the  fundus 
less  quickly,  and  the  pyloric,  as  a  rule,  not  at  all.  Assuming  that 
the  rapidity  of  digestion  of  the  different  portions  is  in  proportion 
to  the  quantity  of  pepsin  present,  it  makes  it  probable  that  most 
pepsin  is  formed  in  the  middle  zone.  Although  it  has  been  proved 
that  pepsin  is  formed  in  glands  which  do  not  contain  border  cells, 
in  general  it  may  be  stated  that  the  amount  of  pepsin  formed  by  the 
different  glands  is  in  proportion  to  the  number  of  border  cells. 

"The  degree  of  acidity  of  the  mucous  membrane  is  in  proportion 
to  the  number  of  border  cells  present.  It  is  reasonable  to  suppose 
that  the  formation  of  acid  in  any  portion  of  the  stomach  aids  materi- 


2  8  HISTOLOGY    OF    THE    STOMACH. 

ally  in  the  formation  of  pepsin  in  the  same  part.  This  is  very  essen- 
tial, because  acid  favors  the  formation  of  pepsin  from  pepsinogen. 
Since  border  cells  are  only  with  the  greatest  difficulty  digested  in 
acid,  we  can  not  ascribe  to  them  the  power  to  secrete  pepsin;  and 
since  the  morphology  of  the  central  cells  varies  during  digestion 
and  rest,  and  they  are  so  easily  digested  upon  the  addition  of  acid, 
we  must  conclude  with  Heidenhain  that  the  former  are  probably 
concerned  in  the  production  of  acid  and  the  latter  in  the  production 
of  pepsin. 

"When  the  stomach  is  forcibly  distended,  it  is  found  that  the 
dilatation  is  mostly  at  the  expense  of  the  fundus.  This  seems  also 
to  be  the  case  when  the  stomach  is  naturally  filled  with  food.  Al- 
though the  middle  zone  is  practically  not  stretched  when  the  stomach 
is  filled,  distention  seems  to  favor  circulation  through  this  part 
because  the  blood-vessels  are  more  easily  injected  in  a  moderately 
distended,  than  in  an  empty,  stomach. 

"In  the  intestine  it  is  found  that  the  longitudinal  and  circular 
muscle-fibers  are  antagonistic.  In  the  stomach  the  pyloric  valve 
is  closed,  after  the  muscle-ceUs  are  dead,  by  a  fold  of  mucous  mem- 
brane being  thrown  into  the  lumen.  This  may  take  place  in  a  living 
stomach.  A  contraction  of  the  circular  muscle  tends  to  strengthen 
this  valve,  while  a  contraction  of  the  longitudinal  muscle  tends  to 
weaken  it,  because  with  the  contraction  of  the  longitudinal  muscle 
there  is  always  an  accompanying  relaxation  of  the  circular  muscle. 
Under  ordinary  circumstances  it  seems  as  though  the  stomach 
reduced  its  lumen  by  simultaneous  contraction  of  both  longitudinal 
and  circular  muscle-fibers.  What  complex  motions  take  place  during 
peristalsis  are  absolutely  unknown.  It  is,  however,  a  remarkable 
fact  that  a  bundle  of  the  circular  fibers  (oblique  fibers)  are  parallel 
with  the  longitudinal  fibers,  which  are  increased  in  number  in  the 
middle  zone.  A  solution  of  this  problem  seems  within  the  range 
of  experimentation. 

"The  celiac  axis  supplies,  besides  the  stomach,  also  the  spleen 
and  the  liver.  With  a  given  pressure  within  the  aorta,  variation  in 
the  resistance  in  the  capillaries  of  the  spleen  and  the  liver  will  have 
a  marked  effect  upon  the  circulation  through  the  stomach.  The 
portion  of  the  stomach  (middle  zone)  supplied  by  the  gastric  artery 
is  to  a  less  extent  under  the  control  of  these  side  influences  than  is 
that  which  is  supplied  by  arteries  arising  from  the  main  branches 
to  the  spleen  and  to  the  liver.     It  must  be  again  stated  that  there 


PLATE  I. 


Three  Sections  of  Stomach-walls  Placed  Side  by  Side  to  Show  the  Positions  of 
Blood-vessels  and  Lymphatics  to  the  Different  Layers.— (/\  Mall,  ''Johns 
Hopkins  Hospital  Reports,^''  Vol.  I.) 

M.  Mucosa.     AH.   Muscularis  mucosse.     S.  Submucosa.     CandZ.  Circular  and  longitudinal 

muscles  enlarged  70  times. 


^iiH  ^1.^ 


w    :2  .2  '-^ 


^  -fi    "* 


JJ    ^  -2 


i3    J3     <u 


bfl    o   .£ 


MUCOSA.  29 

are,  in  all  probability,  many  other  influences  which  play  most  im- 
portant parts  in  the  distribution  of  blood. 

"7.  Around  the  two  curvatures  of  the  stomach  there  is  a  complete 
circle  of  anastomosis,  which  has  a  tendency  to  equalize  the  pressure 
in  the  arteries  penetrating  the  muscle-walls.  But  the  anastomoses 
arising  therefrom  have  only  a  tendency  to  make  gradual  gradations, 
and  not  an  equal  pressure  throughout.  The  additional  set  of  anasto- 
moses within  the  submucosa  are,  again,  not  sufficient  to  equalize 
the  flow  throughout  the  whole  mucosa.  After  ligating  arteries,  as 
well  as  by  examining  the  mucous  membrane,  during  digestion  and 
rest,  it  is  found  that  no  sharp  lines  can  be  drawn. 

"8.  The  blood-vessels  are  arranged  in  such  a  manner  that  from 
any  portion  of  the  submucosa  about  one-fourth  of  the  blood  may 
go  to  the  muscle-coats  and  three-fourths  to  the  mucosa.  It  is  there- 
fore probable  that  when  the  flow  is  poured  to  one  side  it  is  diminished 
to  the  other,  and  vice  versa.  There  is,  however,  a  tendency  to 
equaHze  this  by  the  submucous  anastomoses. 

"9.  Since  there  is  but  one  set  of  arteries  to  the  mucosa,  there 
must  be  but  one  sort  of  circulation,  which  may  vary  in  degree  onl5^ 
Within  the  mucosa  the  arrangement  is  such  that  the  portion  of  the 
gland  which  is  deepest  receives  the  blood  richest  in  O.  The  mucous 
membrane,  omitting  the  muscularis  mucosae,  lies  between  two 
venous  plexuses.  Contraction  of  the  muscle-fibers  between  the 
glands  and  those  of  the  muscularis  mucosae  should  diminish  the 
volume  of  the  mucosa.  This  would  have  a  tendency  to  empty  the 
glands,  as  well  as  to  press  blood  from  the  two  venous  plexuses,  espe- 
cially the  lower.  Whether  or  not  there  is  a  force  within  the  mucosa 
which  can  augment  the  circulation  seems  at  present  impossible  to 
determine  by  experiment.  The  arrangement  of  the  parts  is  very 
suggestive. 

"10.  The  rich  venous  plexus  of  veins  within  the  submucosa  is 
sufficiently  large  to  hold  a  considerable  quantity  of  blood.  This 
must  be  the  case  when  the  valves  within  the  veins  coming  from  the 
stomach  are  temporarily  closed.  When  the  valves  are  closed,  a 
contraction  of  the  circular  muscle  is  sufficient  to  drive  all  the  blood 
from  the  underlying  veins.  It  is  therefore  possible  that  a  rhythmical 
contraction  in  any  part  of  the  stomach  may  favor  the  circulation 
through  its  walls. 

"11.  The  arrangement  of  the  lymphatics  is  much  the  same  as  that 
of  the  veins,  and  the  foregoing  consideration   (10)  applies  equally 


30  HISTOLOGY   OF    THE    STOMACH. 

well  to  them.  When  we  consider  the  resistance  to  be  overcome 
while  the  lymph  passes  through  so  many  networks  before  the  cis- 
terna  chyli  is  reached,  it  makes  it  plausible  to  state  that  the  circu- 
lation is  favored  by  muscular  contraction. 

"  12.  Since  the  blood  which  leaves  the  stomach  must  pass  through 
the  capillaries  of  the  liver,  it  is  necessary  that  it  be  constanth^  under 
a  comparatively  high  pressure.  This  pressure  is  also  dependent  upon 
the  spleen  and  the  intestine.  If  the  pressure  is  high,  a  regurgitation 
into  the  stomach  is  impossible  on  account  of  the  presence  of  valves. 

"13.  In  a  stomach  in  which  the  vessels  are  all  equally  distended 
the  rapidity  of  circulation  in  the  celiac  axis  would  be  263  times 
that  in  the  capillaries.  The  area  of  the  section  of  the  celiac  axis  is 
0.0592  square  cm. ;  the  immediate  branches  to  the  stomach,  0.0348 
square  cm. ;  to  the  spleen  and  liver,  0.0244  square  cm.  All  the 
capillaries  of  the  stomach:  mucosa,  6.4524  square  cm.;  muscle- 
coats,  2.7214  square  cm.;  total,  9.1738  square  cm.;  9.1738  -^  0.0348 
=  263. 

"A  Hke  estimation  shows  that  the  rapidity  of  circulation  in  all 
the  capillaries  is  -g-^-g-  of  that  in  the  arteries  penetrating  the  muscle- 
walls;  while  if  the  capillaries  of  the  muscle- walls  are  excluded,  the 
rapidity  in  the  capillaries  of  the  mucosa  rises  to  -jj. 

"Considering  the  glands  on  an  average  0.05  cm.  long  and  0.003^ 
cm.  in  diameter,  excluding  the  necks,  the  area  of  all  the  glands 
would  be  8671  square  cm.,  or  thirty-eight  times  the  area  of  mucous 
membrane.  A  hke  estimation  of  the  capillaries,  considering  each 
capillary  0.04  cm.  long,  gives  for  them  a  total  area  of  1718  square 
cm.,  or  7^  times  the  mucous  surface.  The  secreting  surface  is  five 
times  that  of  the  blood-supply." 

Vessels  and  Nerves. — The  arteries  supplying  the  stomach  are: 
the  coronaria  ventriculi;  the  pyloric  and  right  gastro-epiploic 
branches  of  the  hepatic;  the  left  gastro-epiploic  and  vasa  brevia 
from  the  splenic.  They  supply  the  muscular  coat,  ramify  in  the 
submucous  coat,  and  are  finally  distributed  to  the  mucous  mem- 
brane. The  arrangement  of  the  vessels  in  the  mucous  membrane 
is  somewhat  pecuHar.  The  arteries  break  up  at  the  base  of  the 
gastric  tubules  into  a  plexus  of  fine  capillaries  which  run  upward 
between  the  tubules,  anastomosing  with  one  another  and  ending  in 
a  plexus  of  large  capillaries  which  surround  the  mouths  of  the  tubes, 
and  also  form  hexagonal  meshes  around  the  alveoli.  (See  Plate  II.) 
The  veins  arise  from  the  latter,  and  pursue  a  straight  course  back 


THE   SMALL   INTESTINE.  3 1 

to  the  submucous  tissue,  between  the  tubules,  to  terminate  in  the 
splenic  and  portal  veins. 

The  lymphatics  are  abundant,  and  may  be  divided  into  a  super- 
ficial and  a  deep  set,  which  pass  through  the  lymphatic  glands  found 
along  the  two  curvatures.  The  nerves  are  supplied  from  the  right 
and  left  pneumogastric,  and  numerous  branches  from  the  abdominal 
sympathetics.     (Solar  plexus.) 


CHAPTER  III. 
THE  SMALL  INTESTINE. 


The  small  intestine  commences  at  the  pylorus,  and  after  many 
convolutions  terminates  in  the  large  intestine.  It  measures,  on  an 
average,  about  twenty-two  feet  in  length  in  an  adult,  and  becomes 
gradually  narrower  from  its  upper  to  its  lower  end.  Its  convolutions 
occupy  the  middle  and  lower  parts  of  the  abdomen,  frequently 
descending  into  the  pelvis. 

The  small  intestine  is  divided  into  three  portions,  which  have  re- 
ceived different  names:  The  first  ten  to  twelve  inches  immediately 
succeeding  the  stomach,  and  comprising  the  widest  and  most  fixed 
part  of  the  tube,  are  called  the  duodenum.  This  part  is  further 
distinguished  by  its  close  relation  to  the  head  of  the  pancreas,  and 
by  the  absence  of  a  mesentery.  The  remainder,  which  is  arbitrarily 
divided  into  an  upper  two-fifths,  called  the  jejunum,  and  a  lower 
three-fifths,  called  the  ileum,  is  very  convoluted  and  movable,  being 
connected  with  the  posterior  abdominal  wall  by  a  long  and  exten- 
sive fold  of  peritoneum  called  the  mesentery,  and  by  numerous 
blood-vessels  and  nerves.  Although  there  is  no  distinct  line  of  de- 
marcation between  the  jejunum  and  the  ileum,  yet  that  portion  of 
the  small  intestine  included  under  these  two  names  gradually  under- 
goes certain  changes  in  structure  and  appearance  from  above  down- 
ward, so  that  the  upper  end  of  the  jejunum  can  readily  be  distin- 
guished from  the  lower  end  of  the  ileum. 

,  Structure  of  the  Small  Intestine. — The  small  intestine,  like  the 
stomach,  is  composed  of  four  coats — viz. :  the  serous  or  peritoneal, 
the  muscular,  the  areolar,  and  the  mucous. 


32  THE   SMALL   INTESTINE. 

The  external,  or  serous,  coat  almost  entirely  surrounds  the  intes- 
tinal tube  in  the  whole  extent  of  jejunum  and  ileum,  leaving  only  a 
narrow  interval  behind,  where  it  passes  off  and  becomes  continuous 
with  the  two  layers  of  the  mesentery.  The  line  at  which  this  takes 
place  is  named  the  attached  or  mesenteric  border  of  the  intestine. 
The  duodenum,  on  the  other  hand,  is  but  partially  covered  by  the 
peritoneum.  The  muscular  coat  consists  of  two  layers  of  fibers — an 
outer  longitudinal,  and  an  inner,  or  circular,  set.  The  longitudinal 
fibers  constitute  an  entire  but  comparatively  thin  layer,  and  are 
most  obvious  along  the  free  border  of  the  intestine.  The  circular 
layer  is  thicker  and  more  distinct. 

The  muscular  tunic  becomes  gradually  thinner  toward  the  lower 
part  of  the  small  intestine.  It  is  pale  in  color,  and  is  composed  of 
plain  muscular  tissue,  the  cells  of  which  are  of  considerable  length. 

The  progressive  contraction  of  these  fibers,  commencing  at  any 
part  of  the  intestine  and  advancing  in  a  downward  direction,  pro- 
duces the  peculiar  vermicular,  or  peristaltic,  movement  by  which  the 
contents  are  forced  onward  through  the  canal.  In  the  narrowing 
of  the  tube  the  circular  fibers  are  mainly  concerned,  the  longitudinal 
fibers  tending  to  produce  dilatation  (Exner) ;  and  those  found  along 
the  free  border  of  the  intestine  may  have  the  effect  of  straightening 
or  unfolding  its  successive  convolutions.  There  is  a  gangliated 
plexus  of  nerve-fibers  and  a  network  of  lymphatic  vessels  between 
the  two  muscular  layers. 

The  submucous  coat  of  the  small  intestine  is  a  layer  of  areolar 
tissue  of  a  loose  texture,  which  is  connected  more  firmly  with  the 
mucous  than  with  the  muscular  coat.  Within  it  the  blood-vessels 
ramify  before  passing  to  the  mucous  membrane,  and  it  contains  a 
gangliated  plexus  of  nerve-fibers  and  a  network  of  large  lymphatic 
vessels. 

The  internal  coat,  or  mucous  membrane,  is  characterized  by  the 
finely  flocculent,  or  shaggy  appearance  of  its  inner  surface,  resem- 
bling the  pile  upon  velvet.  This  appearance  is  due  to  the  surface 
being  thickly  covered  with  minute  processes,  named  villi.  It  is  one 
of  the  most  vascular  membranes  in  the  body,  and  is  naturally  of  a 
reddish  color  in  the  upper  part  of  the  small  intestine,  but  is  paler, 
and  at  the  same  time  thinner,  toward  the  lower  end.  It  is  lined 
with  columnar  epithelium  throughout  its  whole  extent,  and,  next  to 
the  submucous  coat,  is  bounded  by  a  layer  of  plain  muscular  tissue 
(muscularis  nmcosae) ;  between  this  and  the  epithelium  the  substance 


VALVULE   CONNIVENTES.  33 

of  the  membrane,  apart  from  the  tubular  glands,  which  will  be  after- 
ward described,  consists  mainly  of  retiform  tissue,  which  supports 
the  blood-vessels,  nerves,  lymphatics,  and  lacteals,  and  incloses  in  its 
meshes  numerous  lymph-corpuscles. 

Valvulae  Conniventes. — The  mucous  membrane,  in  addition  to 
small  effaceable  folds,  or  rugae,  possesses  also  permanent  folds,  which 
can  not  be  obliterated,  even  when  the  tube  is  forcibly  distended. 
These  permanent  folds  are  the  valvulae  conniventes,  or  valves  of 
Kerkring.  They  are  crescentic  projections  of  the  mucous  mem- 
brane, placed  transversely  to  the  axis  of  the  bowel,  and  following 
one  another  closely.  The  majority  of  the  folds  do  not  extend  more 
than  one-half  or  two-thirds  around  the  interior  of  the  tube,  but  it 
has  been  shown  by  Brooks  and  Kazzander  that  some  form  complete 
circles,  and  others  spirals.  The  spiral  forms  may  occur  singly  or  in 
groups  of  two  or  three.  They  generally  extend  a  little  more  than 
once  around  the  lumen  of  the  bowel,  but  in  rare  cases  may  go  around 
two  or  three  times.  At  their  highest  point  they  project  inward  for 
about  ^  of  an  inch.  Some  of  the  valvulae  conniventes  are  bifurcated 
at  one  or  both  ends,  and  others  terminate  abruptly.  Each  consists 
of  a  fold  of  mucous  membrane — that  is,  of  two  layers  placed  back 
to  back,  and  united  by  submucous  areolar  tissue.  They  contain  no 
part  of  the  circular  or  longitudinal  muscular  coats.  Being  extensions 
of  the  mucous  membrane,  they  serve  to  increase  the  absorbent  surface 
to  which  the  food  is  exposed. 

The  valvulae  conniventes  are  not  uniformly  distributed  over  the 
various  parts  of  the  small  intestine.  There  are  none  just  at  the 
commencement  of  the  duodenum ;  a  short  distance  from  the  pylorus 
they  begin  to  appear;  beyond  the  point  at  which  the  bile  and  pan- 
creatic juice  are  poured  into  the  duodenum  they  are  very  large, 
regularly  crescentic  in  form,  and  placed  so  near  to  one  another  that 
the  intervals  between  them  are  not  greater  than  the  breadth  of  the 
valves;  they  continue  thus  through  the  rest  of  the  duodenum,  and 
along  the  upper  half  of  the  jejunum.  Below  that  point  they  begin 
to  get  smaller  and  further  apart,  and,  finally,  toward  the  middle  or 
lower  end  of  the  ileum,  having  gradually  become  more  irregular 
and  distinct,  sometimes  even  acquiring  a  very  oblique  direction,  they 
disappear  altogether. 

The  villi,  pecuHar  to  the  small  intestine,  and  giving  to  its  internal 
surface  the  velvety  appearance  already  spoken  of,  are  .small  pro- 
cesses of  the  mucous  membrane,  which  are  closely  set  on  every  part 


34  THE    SMALL   INTESTINE. 

of  the  inner  surface  over  the  valvulae  conniventes,  as  well  as  between 
them.  Their  length  varies  from  0.5  mm.  to  0.7  mm.,  or  sometimes 
more. 

They  are  largest  and  most  numerous  in  the  duodenum  and  jeju- 
num, and  become  gradually  smaller  and  fewer  in  number  in  the 
ileum.  According  to  Rauber,  they  are  short  and  leaf-shaped  in  the 
duodenum,  and  as  the  gut  is  followed  downward,  they  become 
gradually  longer  and  thinner,  so  that  they  are  tongue-shaped  in  the 
jejunum  and  filiform  in  the  ileum.  Occasionally,  two  or  three  are 
connected  at  their  bases.  In  the  upper  part  of  the  small  intestine 
there  are  from  10  to  18  vilH  in  a  square  millimeter,  and  in  the  ileum 
from  8  to  14  in  the  same  space.  This  would  give  about  4,000,000 
altogether  (Krause). 

A  villus  consists  of  a  prolongation  of  the  mucous  membrane 
proper.  It  is  covered  by  columnar  epithelium,  and  incloses  a  net- 
work of  blood-vessels,  one  or  more  lymphatic  vessels  (lacteals),  and 
a  few  longitudinal,  plain,  muscular  fiber-cells,  these  being  all  sup- 
ported and  held  together  by  retiform  lymphoid  tissue. 

Under  the  epithelium  is  a  basement  membrane  composed  of  flat- 
tened cells  which,  on  the  one  hand,  are  connected  with  the  branched 
cells  of  the  retiform  tissue,  and,  on  the  other  hand,  send  processes 
between  the  epithelial  cells.  Nervous  fibrils  penetrate  into  the  villi 
from  the  plexus  of  Meissner,  and  form  arborizations  throughout  their 
whole  substance. 

Bach  villus  receives,  as  a  rule,  one  small  arterial  twig,  which  runs 
from  the  submucous  coat  through  the  muscularis  mucosae  to  the 
base  of  the  villus,  and  then  up  the  center  to  near  the  middle  line  of 
the  villus,  where  it  begins  to  break  up  into  a  number  of  capillaries. 

These  form,  near  the  surface,  a  fine  capillary  network  beneath 
the  epithelium  and  limiting  membrane,  from  which  the  blood  is 
returned,  for  the  most  part,  by  one  or  two  venules  which,  in  man, 
commence  near  the  tip  of  the  villus,  and  pass  down  to  its  base  to 
join  the  venous  plexus  of  the  mucous  membrane,  whence  the  blood 
is  conveyed  to  the  large  veins  of  the  submucosa. 

The  lacteal  lies  in  the  center  of  the  villus,  and,  in  the  smaller 
villi,  is  usually  a  single  vessel  with  a  closed  and  somewhat  expanded 
extremity,  and  of  considerably  larger  diameter  than  the  capillaries 
of  the  blood-vessels  around.  In  the  human  subject  there  are  never 
more  than  two  intercommunicating  lacteals  in  a  single  villus. 

The  lacteals  in  the  villi  are  bounded  by  a  delicate  layer  of  flat- 


the;  villi.  35 

tened  epithelial  cells;  these  are  connected  with  the  branched  cells 
of  the  tissue  of  the  villus,  and  these  again  with  the  flattened  cells 
forming  the  basement  membrane;  from  the  latter,  prolongations 
extend  between  the  epithelial  cells  toward  the  surface.  Briicke  first 
discovered  the  muscular  tissue  within  the  villus,  consisting  of  tm- 
striated,  plain  fiber-cells,  disposed  longitudinally  around  the  lacteal. 
These  fibers  are  prolongations  of  the  muscularis  mucosae. 

When  they  are  stimulated  in  animals,  a  very  evident  retraction 
of  the  villus  is  observable. 

The  fiber-cells  at  the  sides  and  toward  the  end  of  the  villus  pass 
from  the  lacteal  to  be  attached  to  the  basement  membrane  in  a 
bifurcating  manner. 

Columnar  epithelial  cells  cover  not  only  the  villi,  but  also  the 
rest  of  the  surface  of  the  small  intestine,  and  extend  into  the  tubular 
glands.  There  is  never  any  continuity  between  the  extremity  that 
is  attached  to  the  basement  membrane  and  the  branched  corpuscles 
of  the  retiform  tissue  of  the  villus.  This  epithelium  separates  easily 
from  the  subjacent  tissue.  Between  the  cells  composing  it  is  a 
variable  number  of  leukocytes,  most  numerous  in  the  lower  part  of 
the  intestines  near  the  lymphoid  follicles.  Occasionally,  they  are 
seen  to  be  free  in  small  lymph-spaces  between  the  columnar  epi- 
thelial cells  and  showing  indications  of  karyokinesis.  Hardy  de- 
clares that  immediately  below  the  columnar  epithelium  of  the  villi 
there  is  frequently  a  well-marked  layer  of  cells  that  stain  readily 
with  eosin.     Hence  he  calls  these  cells  eosinophilic. 

Among  the  ordinary  epithelial  cells  of  the  villus  are  others,  the 
outer  half  of  which  is  filled  with  mucigen,  and  at  times  beaker- 
or  cup-shaped  empty  cells  are  observed  from  which  this  has  been 
discharged  as  mucus,  the  free  end  being  ruptured  ;>•  these  are  some- 
times called  the  goblet-cells.  The  number  of  cells  containing  mucus 
varies  much  in  different  animals  and  under  different  conditions  in 
the  same  animal.  There  are  comparatively  few  mucous  cells  in  the 
glands  of  the  small  intestine. 

The  epithelial  cells  are,  as  far  as  can  be  ascertained,  the  principal 
agents  in  promoting  the  absorption  of  food  materials  from  the  in- 
terior of  the  gut,  and  the  seat  of  the  retrograde  processes  of  metabol- 
ism which  the  products  of  digestion  undergo  during  absorption. 
Peptone,  when  injected  into  the  blood  of  an  animal  by  whose  gastric 
juice  it  has  been  formed,  acts  as  a  poison.  It  is  due  to  these  epi- 
thelial cells  of  the  intestine  that  peptone  is  so  modified  during  absorp- 
tion that  it  becomes  of  use  to  the  organism. 


36  THK   SMALL   INTESTINE. 

Most  food  particles  can  not  be  traced  in  microscopic  specimens, 
but  fatty  or  oily  substances,  from  their  property  of  becoming  stained 
with  osmic  acid,  can  be  followed  out  to  some  extent.  The  examina- 
tion of  such  specimens,  taken  during  digestion  of  a  meal  containing 
fat,  shows  the  epithelial  cells  turbid  with  oil  droplets  in  their  in- 
terior; and  in  some  animals,  at  a  subsequent  stage,  ameboid  cells 
appear  within  the  tissue  of  the  villus  pervaded  with  similar  but  finer 
fatty  particles,  and  eventually  the  central  lacteal  becomes  filled  with 
these.  It  is  probable  that  these  ameboid  lymph-corpuscles,  appear- 
ing so  abundantly  within  the  villus  and  among  the  epithelial  cells 
on  its  surface,  play  an  important  part  in  the  transference  of  such 
particles  from  the  epithelial  cells  in  the  lacteal;  for  at  certain  stages 
of  fat  absorption  they  contain  abundant  fatty  particles.  Recent 
investigations  point  to  the  absorption  of  the  larger  portion  of  fats 
in  form  of  fatty  acids  and  soaps.  The  present  state  of  our  knowledge 
on  the  subject  of  the  emulsion  and  solution  theories  of  fat-absorption 
is,  in  the  author's  opinion,  by  no  means  sufficiently  matured  to 
justify  a  scientific  conclusion  in  favor  of  either  hypothesis  to  the 
exclusion  of  the  other.  The  large  amount  of  lymphoid  tissue  in  the 
lower  part  of  the  small  intestine  seems  to  be  related  to  a  greater 
power  of  absorption  in  that  part. 

In  the  transference  of  carbon  particles  in  the  lungs,  from  the 
interior  of  the  alveoli  into  the  lymphatics,  which  at  least  in  part  is 
due  to  the  action  of  ameboid  cells,  we  have  an  analogous  process. 

Glands. — Two  kinds  of  true  secreting  glands  are  found  in  the 
intestine;  these  are:  (i)  the  glands  or  crypts  of  Ivieberkiihn  and  (2) 
the  glands  of  Brunner.  In  addition  to  these,  there  are  found  also 
two  varieties  of  intestinal  lymph-follicles,  (i)  the  solitary  and  (2) 
the  agminate  glands,  the  latter  often  designated  as  Peyer's  patches. 

Although  the  solitary  and  agminated  lymph-follicles  have  no 
ducts  opening  upon  the  inner  intestinal  surfaces,  like  Brunner's  and 
lyieberkiihn's  glands,  they  are  nevertheless  spoken  of  as  glands. 

The  follicles,  crypts,  or  glands  of  Lieberklihn  are  tubular  pits 
lined  by  columnar  epithelium,  occurring  between  the  villi.  Here 
and  there  in  these  crypts,  goblet-cells  occur  in  the  epithelium.  They 
are  present  throughout  the  large  and  small  intestine,  and  extend 
through  the  entire  depth  of  the  mucosa,  their  ends  approaching  the 
muscularis  mucosae. 

The  duodenum  possesses  an  additional  layer  of  true  secreting 
structures  in  the  glands  of  Brunner.     They  would  appear  to  rep- 


THE   BLOOD-VESSELS   OF   THE    INTESTINES.  37 

resent  the  direct  continuations  and  higher  speciaHzations  of  the 
pyloric  glands.  In  passing  from  the  stomach  into  the  intestines, 
these  tubules  undergo  repeated  division,  at  the  same  time  sinking 
deeper  into  the  mucosa,  finally  reaching  below  this  layer  to  take  up 
a  position  within  the  submucosa  of  the  duodenum,  underneath  the 
overlying  layer  of  the  crypts  of  Lieberkiihn,  which  are  contained 
in  the  mucosa  proper.  Brunner's  glands  belong  to  the  racemose 
type,  and  under  the  microscope  they  consist  of  a  number  of  tubular 
alveoli  connected  by  terminal  ramifications  of  the  duct  which  pene- 
trates the  muscularis  mucosae,  and  opens  either  between  the  mouths 
of  the  Lieberkiihn  crypts  or  sometimes  into  their  bases. 

The  solitary  glands  are  isolated  lymph-follicles  scattered  through 
the  entire  intestine,  most  abundant  in  the  lower  ileum.  Situated  in 
the  mucosa,  at  times  in  the  submucosa,  the  lymphoid  tissue  in  them 
is  denser  toward  the  periphery,  but  is  everywhere  so  closely  packed 
that  the  supporting  reticulum  of  connective  tissue  is  masked. 

The  agminated  glands,  or  Peyer's  patches,  are  large,  oval  aggre- 
gations of  lymph-follicles  held  together  by  diffuse  adenoid  tissue, 
limited  to  the  lower  two-thirds  of  the  small  intestine.  Development 
of  these  is  most  perfect  in  the  ileum;  appearing  first  within  the 
mucosa,  they  later  encroach  upon  the  submucous  tissue. 

Where  the  summits  of  these  follicles  impinge  against  the  inner 
layer  of  the  mucosa,  the  position  of  the  agminated  glands  is  indi- 
cated by  an  elevation  corresponding  to  them  on  the  mucous  surface. 
In  that  case  the  villi  are  frequently  pushed  aside. 

The  Blood-vessels  of  the  Intestines. — The  vessels  follow  the 
general  arrangement  of  those  in  the  stomach,  the  larger  ones  piercing 
the  serous  and  muscular  coat,  giving  off  slender  twigs  to  supply 
these  tunics,  and  when  they  enter  the  submucosa,  the  vessels  form 
a  wide-meshed  network.  Many  branches  then  pass  through  the 
muscularis  mucosae,  to  be  distributed  to  the  deeper,  as  well  as  the 
superficial,  part  of  the  mucosa.  Around  the  tubular  glands  a  net- 
work is  formed  by  narrow  capillaries,  and  just  beneath  the  epithe- 
lium the  capillaries  become  wider  and  encircle  the  mouths  of  the 
follicles.  From  this  superficial  capillary  network  the  veins  arise, 
and,  passing  down  between  the  follicles,  join  the  deeper  venous 
plexus,  this  in  turn  communicating  with  the  larger  veins  of  the 
submucosa. 

The  villi  have  special  additional  arteries  running  to  their  bases, 
expanding  into  capillaries,  and  then  extending  beneath  the  epithe- 


38  THE    SMALL    INTESTINE. 

Hum  and  around  the  central  lacteals  as  far  as  the  ends  of  the  villi. 
These  capillaries  terminate  in  venous  stems  which  descend  almost 
perpendicularly  into  the  mucosa,  in  their  course  receiving  the  super- 
ficial capillaries  encircling  the  gland-ducts.  Brunner's  glands,  and 
the  solitary  and  agminated  follicles,  are  supplied  from  the  submucosa 
by  vessels  terminating  in  capillary  networks  distributed  to  the  acini 
of  the  glands  and  interior  of  the  lymph-follicles. 

The  blood-vessels  of  the  intestines,  taken  as  a  whole,  constitute  a 
mighty  vascular  territory  which  is  capable  of  taking  up  one-third 
of  the  total  amount  of  blood  of  the  body. 

The  arteries  are  all  branches  of  the  superior  and  inferior  mesen- 
teric arteries,  which  run  along  and  approach  the  gut  in  the  mesen- 
tery. The  intestinal  veins  form  the  principal  portion  of  the  portal 
system. 

Lymph-vessels. — The  beginning  of  the  lymph-vessels  can  be 
traced  to  the  lacteals  within  the  vilh,  where  they  begin  as  tiny, 
blind  pouches  at  the  apex  of  the  villus.  In  some  broad  vilU  there 
are  two  such  lymph-vessels  that  anastomose  with  each  other.  From 
here  they  run  down  in  the  septa  between  the  glands  in  the  lymph- 
vessel  meshwork  over  the  muscularis  mucosae.  Here  they  again 
anastomose  with  an  outer  lymph-vessel  network  in  the  submucosa. 
Here  the  lymphatics  begin  to  be  provided  with  valves. 

The  nerves  of  the  intestine,  like  those  of  the  stomach,  originate 
chiefly  from  the  mesenteric  plexus,  which  is  formed  by  branches 
from  the  celiac  plexus,  the  semilunar  ganglion,  and  vagus  nerve, 
consisting  of  medullated  and  non-medullated  fibers  that  begin  to 
form  an  abundant  network  under  the  peritoneum  of  the  intestine, 
then  penetrate  the  longitudinal  muscular  stratum,  and  between  this 
and  the  circular  layer  form  a  pecuhar  plexus  with  numerous  micro- 
scopical ganglia,  constituting  the  plexus  of  Auerbach. 

In  the  submucosa  a  similar  network  of  fibers  and  ganglia  has  been 
termed  Meissner's  plexus.  From  Meissner's  plexus  very  fine  fibers 
are  spun  about  the  Lieberkiihn  crypts,  villi,  and  limiting  membrane. 

Relations  of  the  Duodenum.— This  part  of  the  gut  in  the  adult 
is  horseshoe  shaped,  generally  presenting  well-marked  angles,  which 
divide  it  into  four  parts  having  four  distinct  directions;  these  are: 
(i)  The  horizontal  or  superior  part,  running  backward  from  the 
pylorus,  to  the  right,  in  contact  with  the  quadrate  lobe  of  the  liver, 
to  the  under  side  of  the  neck  of  the  gall-bladder,  where  it  cur\^es 
sharply  downward  to  join  the  second  part.     This  first  or  horizontal 


RELATIONS    OF   THE   DUODENUM. 


39 


part  is  about  two  inches  long  when  the  stomach  is  empty.  (2)  The 
second  or  descending  portion  is  about  three  inches  long,  and  com- 
mences just  below  the  neck  of  the  gall-bladder  opposite  the  right 
side  of  the  first  lumbar  vertebra,  and  passes  down  to  the  level  of  the 
third  or  fourth  lumbar  vertebra,  where  it  turns  sharply  inward  to 
join  the  third  part.  (3)  The  third  or  transverse  portion  is  from  two 
to  three  inches  long;  beginning  at  the  right  of  the  third  or  fourth 
lumbar  vertebra,  it  crosses  over  to  the  left  side  with  a  slight  upward 
inclination,  and  ends  to  the  left  of  the  aorta  by  curving  upward  to 


Fig.  4.— Plaster  Casts  of  Duodenum  of  Infant  and  Adult. — [From  Museum  of  Harvard 

University. ) 
A.  Infant  duodenum.     B.  Adult.    V.  Valvulae  conniventes.    P.  Pvlorus. 


join  the  terminal,  (4)  fourth,  or  ascending,  portion,  which  is  about 
two  inches  long ;  it  passes  upward  to  the  left  side  of  the  aorta,  as  high 
as  the  upper  border  of  the  second  lumbar  vertebra;  here  it  turns 
abruptly  forward  to  join  the  jejunum,  forming  the  duodenojejunal 
flexure. 

Thus  the  end  of  the  duodenum  is  brought  to  the  same  level  as 
the  beginning.  It  has  been  compared  to  a  water-trap,  its  ends 
being  always  higher  than  its  middle,  which  is  thus  fitted  to  retain 
the  fluid  poured  into  it  from  the  liver,  pancreas,  and  its  own  glands, 


40  THE    SMAIvIv   INTE^STINE. 

besides  that  which  it  receives  from  the  stomach,  at  the  same  time 
preventing  the  regurgitation  of  gases  from  the  jejunum  into  the 
pyloric  part  of  the  duodenum  and  stomach. 

Jejunum  and  Ileum. — The  upper  two-fifths  of  the  remaining 
intestine  immediately  following  the  duodenum  are  called  the  jejunum  ; 
the  lower  three-fifths,  the  ileum.  Both  are  attached  to  the  posterior 
abdominal  wall  by  an  extensive  fold  of  peritoneum, — the  mesentery. 

The  jejunum  lies  above  and  to  the  left  of  the  ileum,  but  the  coils 
are  so  irregular  that  the  position  of  any  individual  loop  affords  but 
little  clue  to  the  part  of  the  intestine  to  which  it  belongs. 

The  large  intestine  consists  of  the  cecum,  the  colon,  and  the  rectum. 
The  colon  is  subdivided,  according  to  the  directions  it  takes,  into 
four  parts,  which  are  (i)  the  ascending,  (2)  transverse,  (3)  descend- 
ing, and  (4)  sigmoid  colon  or  flexure. 

The  end  of  the  ileum,  which  rises  out  of  the  pelvis  to  the  right 
iliac  fossa,  is  not  inserted  into  the  beginning  of  the  large  intestine, 
but  above  the  beginning  and  at  the  side  of  it.  The  part  of  the  large 
intestine  below  this  insertion  is  a  blind  pouch, — the  cecum.  From 
the  inner  and  back  part  of  the  cecum,  a  little  below  the  ileocolic 
opening,  a  narrow,  round,  worm-like .  process,  about  two  or  three 
inches  long,  is  given  off, — the  vermiform  appendix. 

The  cecum  continues  upward  into  the  ascending  colon,  which 
rises  up  in  front  of  the  right  kidney  to  the  edge  of  the  liver;  then 
this  same  large  intestine  passes  beneath  the  greater  curvature  of  the 
stomach,  and  horizontally  across  to  the  left  side,  as  the  transverse 
colon;  here,  at  the  lower  border  of  the  spleen,  it  turns  downward  as 
the  descending  colon. 

This  large  gut  describes  two  right-angled  curves,  the  right  and 
left  colonic  flexures  fixed  by  the  hepatocolic  and  gastrocolic  liga- 
ments respectively.  The  descending  colon  continues  into  the  sig- 
moid colon  or  flexure,  which  connects  it  with  the  rectum.  The 
rectum,  following  the  curves  of  the  sacroiliac  symphysis  and  the 
hollow  of  the  sacrum,  has  itself  two  curves:  an  upper  larger  curve, 
concave  anteriorly,  and  a  lower  smaller  curve,  convex  anteriorly. 

Only  the  cecum,  transverse  colon,  and  sigmoid  colon  have  a  com- 
plete peritoneal  covering;  the  rest  of  the  large  gut  is  only  covered 
anteriorly.  From  the  third  sacral  vertebra  on,  the  rectum  has  no 
peritoneum.  Those  parts  having  no  complete  peritoneum,  therefore, 
have  no  mesentery,  and  are  not  very  movable.  The  longitudinal 
fibers  are  contracted,   or  narrowed  down  to  three  parallel  bands 


FOOD   SUBSTANCES.  4 1 

(Fasciae  teniae,  or  ligamenta  coli).  One  of  these  bands  runs  along 
the  attachment  of  the  gastrocoHc  Hgament  on  the  transverse  colon 
(fascia  omentalis),  the  second  along  the  mesenteric  border,  and  the 
third  is  free. 

Running  down  into  the  rectum  these  bands  become  so  broad  that 
they  occupy  the  entire  periphery  of  the  tube.  These  longitudinal 
bands  being  shorter  than  the  other  layers  of  the  wall  of  the  colon, 
they  bring  about  the  characteristic  sacculation  of  the  large  intestine. 
In  the  lower  part  of  the  rectum  the  circular  muscular  layer  becomes 
thickened  to  form  the  internal  anal  sphincter  of  involuntary  fibers. 

The  external  sphincter  is  composed  of  striated  voluntary  muscle- 
fibers.  The  histology  of  the  large  intestine  differs  from  that  of  the 
small  by  the  absence  of  the  villi  and  the  larger  size  of  the  crypts 
and  follicles.  Several  longitudinal  elevations  over  the  anus  are  called 
the  columns  of  Morgagni;  from  this  point  downward  the  cylindrical 
epithelium  ceases  to  exist  and  flat  pavement  epithelium  takes  its 
place. 


CHAPTER  IV. 
PHYSIOLOGY  OF  DIGESTION. 


Food  Substances. — The  simple  chemical  elements  of  the  various 
food  substances,  namely,  C,  H,  N,  S,  and  P,  are  not  assimilable  as 
such,  because  the  human  body  is  not  capable  of  constructing  higher 
compounds  from  them.  It  is  compelled  to  take  in  these  compounds 
in  the  form  of  proteid  or  albuminous  substances,  carbohydrates,  and 
fats,  together  with  such  inorganic  bodies  as  water  and  salts. 

Even  these  food-stuffs,  which  are  essential  for  the  maintenance 
and  development  of  the  organism,  are  not  ingested  as  such,  but  are 
contained,  together  with  innutritions  materials,  in  the  various 
articles  of  diet  which  we  derive  from  the  animal  and  vegetable 
kingdoms. 

The  innutritions  admixtures  of  the  food  substances  are  not  harm- 
ful, but  are  important  as  stimulants  to  the  intestinal  mucosa  and 
to  the  evacuation  of  feces.  Among  these  innutritions  substances 
are  classed  the  connective  tissue,  cartilages  and  tendons  of  meat, 
and  the  cellulose  of  plants. 


42  PHYSIOIvOGY   OF    DIGESTION. 

Water  plays  a  most  important  role  in  the  economy  of  the  body, 
for  it  goes  to  make  up  sixty  per  cent,  of  the  total  organism.  We  lose 
about  2^  liters  of  water  in  twenty-four  hours,  through  insensible 
perspiration,  secretion,  and  defecation.  About  300-400  gm.  of  water 
are  formed  by  oxidations  of  food  substances  in  twenty-four  hours; 
so  we  have  a  deficit  of  1500- 1600  gm.,  which  must  be  supplied  by 
the  daily  consumption  of  a  corresponding  amount  of  water;  this  is 
done  principally  by  the  drinking  of  water  after  we  have  taken  in 
part  of  it  by  our  foods,  or  in  the  shape  of  beverages  (soups,  milk, 
fruits,  vegetables,  potatoes,  beer,  wine,  coffee,  tea,  etc.). 

In  mineral  substances  we  must  supply  the  daily  loss  of  sodium 
chlorid  and  other  salts,  particularly  compounds  of  iron.  These  are 
normally  introduced  in  sufficient  quantities  in  food  and  drink. 

The  chief  constituents  of  food — albuminous  bodies,  fats,  and 
carbohydrates — are  of  organic  nature.  The  proteids,  or  albuminous 
bodies,  and  the  fats,  are  derived  partly  from  the  animal  and  partly 
from  the  vegetable  kingdom.  The  carbohydrates  are  almost  exclu- 
sively derived  from  the  vegetable  kingdom.  The  former  serve  for  the 
building  up  of  the  organism,  and  the  continuance  of  life  processes. 
The  latter  are  the  prevailing  sources  of  heat  and  force ;  in  the  pro- 
cess of  oxidation  they  finally  reach  the  stages  of  H2CO3  and  HjO. 

In  addition  to  these,  a  number  of  other  substances  occur  in  the 
food  that  are  oxidized,  and  might  serve  as  sources  of  energy;  these 
are  the  nitrogen-free  vegetable  acids,  the  amido-acids,  and  alcohol, 
for  instance;  quantitatively,  however,  they  are  not  important. 

Other  organic  bodies  that  are  contained  in  food  materials  as 
normal  constituents,  such  as  creatin  in  meat,  glucosids,  alkaloids, 
and  ethereal  oils  in  vegetables  and  spices,  pass  through  the  body 
without  being  oxidized  or  assimilated;  they  are  not  foods,  as  they 
do  not  enter  the  metabohsm  of  the  body,  nor  do  they  develop  energy 
by  chemical  transformation.  However,  a  number  of  these  are  of 
importance  in  nutrition,  as  they  render  the  food  more  palatable, 
and  stimulate  the  secretions  and  the  motility  of  the  digestive  tract. 

It  has  been  said  that  the  elements  S,  P,  CI,  K,  Na,  Ca,  Fe,  Mg 
are  not  food  materials,  but  it  must  not  be  understood  that  they  are 
entirely  useless.  They  are  of  some  significance  in  the  construction 
of  tissue,  although  the  organism  can  derive  no  energy  from  them, 
as  they  are  always  taken  in  a  highly  oxidized  state,  and  leave  in  the 
same  condition.  Nevertheless,  the  body  will  suff'er  if  any  one  of 
these  elements  be  excluded  from  the  food. 


CALORIC    VALUES.  43 

A  certain  minimum  of  these  elements — the  amount  has  not  yet 
been  ascertained — is  absolutely  necessary.  Outside  of  the  sub- 
stances named,  the  food  contains,  as  previously  stated,  a  number 
of  materials  that  are  not  at  all  absorbable  or  digestible,  and  leave 
the  digestive  tract  in  an  unchanged  form;  this  is  the  slag  and  dross 
of  the  food,  and  is  taken  into  the  body  principally  with  vegetables. 

The  normal  adult  human  organism  daily  loses  by  its  metabolism 
1 20  gm.  of  albuminous  or  proteid  bodies,  80  gm.  fat,  400  gm.  carbo- 
hydrates, 25  gm.  salts,  and  2^  liters  of  water.  Accordingly,  a 
corresponding  amount  of  food-stuffs  must  be  introduced  in  the  diet. 
The  articles  of  food  contain  these  nutritious  substances  in  a  variety 
of  proportions.  The  rational  combination  of  these  substances  is 
one  of  the  objects  of  dietetics.  Oilman  Thompson  ("Dietetics") 
divides  foods  into  six  groups,  as  follows:  (i)  Water;  (2)  salts;  (3) 
proteids  (chiefly  albuminous  and  allied  gelatins);  (4)  starches;  (5) 
sugar;  (6)  fats  and  oils. 

It  still  remains  extremely  difficult,  in  the  case  of  all  foods,  to 
trace  their  final  uses  in  the  body,  and  determine  with  any  accuracy 
what  proportions  each  furnish,  respectively,  of  energy,  repair  of 
tissue,  and  heat;  for  there  are  no  more  complex  chemical  processes 
known  than  those  of  metabolism.  Foods  have  three  kinds  of  values : 
(i)  nutrient,  (2)  heat-producing,  (3)  force-producing. 

Caloric  Values. — The  calculation  of  these  different  values  for 
each  kind  of  food  has  been  much  simplified  by  the  introduction  of 
the  conception  of  calories  into  the  doctrines  of  nutrition.  Formerly, 
investigators  said:  "A  healthy  man  needs  so  many  gm.  proteid, 
so  many  gm.  carbohydrates,  so  many  gm.  fat,"  etc.  It  proved 
inconvenient  to  reckon  with  three  magnitudes,  and  to  bring  them 
into  correct  relation  with  the  requisites  of  the  individual  organism. 

Nowadays  we  compute  the  values  of  food-stuffs  according  to  the 
physiological  (kinetic)  energy  liberated  in  their  oxidation.  Oer- 
mans  call  this  "degree  of  energy,"  which  is  always  expressed  in 
terms  of  heat,  the  Brenmverth  ("fuel  value") — i.  e.,  the  value  of  food 
when  it  is  burned  in  the  process  of  metabolism,  for  this  is  nothing 
but  a  slow  combustion.  Now,  the  unit  for  measurement  of  this 
heat  energy  of  food  is  called  a  calory.  This  capacity  for  heat  pro- 
duction of  foods  is  determined  from  the  amount  of  heat  which  is 
liberated  when  any  particular  food-substance  is  transformed  from  its 
original  composition  when  it  entered  the  body, — by  oxidation, — 
into  those  chemical  combinations  in  which  it  leaves  the  organism. 


44  PHYSIOLOGY    OF    DIGESTION. 

The  unit  for  measurement,  or  the  calory,  signifies  the  amount  of 
heat  which  is  necessary  to  raise  one  kilogram  of  water  i°  C. 

I  gm.  of  albumin  furnishes 4.  i  calories. 

I         "     carbohydrate  furnishes 4.1       '' 

I         "     fat  " 9-3       " 

I         "     alcohol  "  7  " 

Instead  of  saying  a  man  requires  100  gm.  albumin,  100  gm.  fat, 
and  400  gm.  carbohydrates,  one  now  expresses  this  in  calories,  thus : 
A  man  requires 

100  gm.  albumin  X     4-f> 410  calories. 

100  gm.  fats  X     9-3. 93° 

400  gm.  carbohydrates  X     4-ii 1 640        " 

Total, 2980 

For  every  kilogram  of  body- weight,  an  adult  requires,  when  at 
rest,  a  food-supply  of  30  to  34  calories;  during  light  occupation,  a 
food-supply  of  34  to  40  calories;  during  medium  occupation,  a  food- 
supply  of  40  to  45  calories;  during  hard  work,  a  food-supply  of  45  to 
60  calories. 

In  very  obese  persons  the  requirements  for  food  are  less  than  the 
quantities  stated  by  one-quarter  to  one-third.  If  the  above  calcu- 
lations of  the  requisite  number  of  calories  per  kilogram  weight  of  any 
person  are  correct,  and  the  supply  maintained  accordingly,  the 
individual  will  maintain  his  weight.  If  the  supply  of  calories  is 
greater,  he  will  gain  weight ;  if  the  supply  is  less,  he  will  lose  weight. 

In  a  condensed  statement  of  facts  like  the  present,  it  will  be  ex- 
pedient to  pass  over  the  physiology  of  hunger,  appetite,  and  thirst, 
which  will  be  considered  in  the  clinical  part  of  this  work  (bulimia, 
anorexia,  etc.),  and  proceed  at  once  to  the  study  of  digestion. 

Ptyalin  Digestion. — Digestion  really  begins  in  the  mouth,  where 
the  food  is  chewed  into  small  bits  and  mixed  with  the  saliva,  which 
mechanically  facilitates  the  mastication  and  deglutition.  Chemical 
transformation  also  begins  here,  for  the  diastasic  ferment  of  saliva 
— ptyalin — transforms  a  small  portion  of  the  starchy  foods  into  mal- 
tose and  dextrose. 

Ptyalin  can  produce  this  transformation  of  starchy  foods  only  in 
an  alkaline  medium;  accordingly  the  action  ceases  in  the  stomach; 
but  not  immediately,  however,  as  the  conversion  of  starches  into 
sugar  goes  on  until  the  degree  of  acidity  reaches  i :  1000.  As  the 
ptyalin  ferment  becomes  inactive  in  this  acidity,  the  question  arises. 


DIGESTION   OF   STARCHES.  45 

whether  its  activity  is  permanently  destroyed  by  an  acidity  of 
I  :  1000,  or  only  temporarily,  and  whether  it  can  resume  its  inverting 
power  when  the  acid  is  neutralized.  Boas,  who  attempted  a  solu- 
tion of  this,  came  to  the  conclusion  that  subsequent  alkalinization, 
or  diminution  of  the  acid,  causes  the  ptyalin  to  act  again,  so  that  in 
later  stages  of  digestion,  when  the  acid  production  ceases,  the  con- 
version of  starch  into  grape  sugar  by  ptyalin  may  be  resumed,  but 
the  ferment  never  becomes  as  active  as  before. 

The  existence  of  appetite  is  to  a  degree  dependent  upon  the  proper 
functioning  of  the  salivary  glands. 

Digestion  of  Starches. — In  order  to  understand  the  various  stages 
of  starch  conversion,  it  is  essential  to  study  the  digestion  of  starch  by 
ptyahn  in  the  laooratory.  There  are  recognized  four  stages  of  starch 
conversion,  each  distinct  from  the  other,  until  dextrose  is  reached. 

1.  (a)  This  is  common  starch,  representing  a  glue-like,  muci- 
laginous jelly,  not  a  clear  solution,  giving  a  dark-blue  color  with 
iodin  in  iodid  of  potassium  solution.  The  next  stage  shows  the  first 
action  of  ptyaUn. 

(b)  Amidulin  or  Amylodextrin. — This  still  gives  a  distinctly  blue 
color,  though  not  so  deep  as  No.  i  (a),  with  Lugol's  solution;  but 
amylodextrin  is  a  soluble  starch,  and  represents  a  real  solution. 

2.  (a)  Erythro dextrin. — Gradually,  as  the  inversion  progresses,  the 
color  produced  by  the  iodin  solution  becomes  violet-blue,  violet, 
red  violet,  red,  or  mahogany  brown;  this  modification  is  called 
erythrodextrin. 

(6)  ' Achroodextrin. — With  continued  action  of  the  ptyalin,  a  sub- 
stance is  reached  which  gives  no  color  with  iodin ;  this  is  called  achro- 
odextrin. Amidulin  is  precipitated  by  tannic  acid  and  alcohol,  but 
erythrodextrin  and  achroodextrin  are  precipitated  by  alcohol  and 
ether,  not  by  tannic  acid.  These  two  dextrins  do  not  reduce  Fehl- 
ing's  solution,  and  do  not  ferment  with  yeast. 

3.  Maltose. — Soluble  in  alcohol,  insoluble  in  ether;  reduces  Fehl- 
ing's  solution,  but  not  Barfoed's  reagent  (a  four  per  cent,  solution 
of  cupric  acetate  to  which  one  per  cent,  acetic  acid  is  added) ;  does 
not  ferment  with  yeast. 

4.  Dextrose. — Insoluble  in  alcohol  and  ether;  reduces  Fehling's  as 
well  as  Barfoed's  solution;  ferments  readily  with  yeast. 

It  is  important  to  familiarize  one's  self  with  these  reactions,  as  it 
often  becomes  necessary  to  determine  the  degree  of  starch  conversion 
in  cases  of  hyperacidity  or  supersecretion. 
4 


46 


PHYSIOLOGY   OF   DIGESTION. 


It  was  formerly  thought  that  the  starch  was  first  converted  to 
dextrin,  and  this  in  turn  was  converted  to  sugar.  According  to 
Professor  W.  H.  Howell  ("Amer.  Textbook  of  Physiology"),  the 
starch  molecule,  which  is  quite  complex,  consisting  of  some  multiple 
of  CgHioOs, — possibly  (C6Hio05)20, — first  takes  up  water,  thereby 
becomes  soluble  (soluble  starch,  amylodextrin),  and  then  splits  with 
the  formation  of  dextrin  and  maltose,  and  that  the  dextrin  again  un- 
dergoes the  same  hydrolytic  process  and  may  continue  under  favor- 
able conditions  until  only  maltose  is  present.  The  difficulty  at 
present  is  in  isolating  the  different  forms  of  dextrin  that  are  produced. 
It  is  usually  said  that  at  least  two  forms  occur,  one  of  which  gives  a 
red  color  with  iodin,  and  is  known  as  erythrodextrin,  while  the  other 
gives  no  color  reaction  with  iodin,  and  is  termed  achroodextrin.  It 
is  pretty  certain,  however,  that  there  are  several  forms  of  achro- 
odextrin, and,  according  to  some  observers  also,  erythrodextrin  is 
really  a  mixture  of  dextrins  with  maltose  in  varying  proportions. 
In  accordance  with  the  general  outline  of  the  process  given  above, 
Neumeister  proposes  the  following  schema,  which  is  useful  because 
it  gives  a  clear  representation  of  one  theory,  but  which  must  not  be 
considered  as  satisfactorily  demonstrated : 


Starch — Solu- 
ble Starch. 
Amylodex- 
trin. 


Maltose. 


Erythro- 
dextrin. 


Maltose. 


Achroo- 
^  dextrin. 


Maltose. 

Achroo- 
dextrin. 


Maltose. 

Achroo- 
dextrin. 
(Malto- 
dextrin.! 


Maltose. 


Maltose. 


Von  Mehring  and  Ewald  have  shown  that  in  the  transformation 
of  starch  into  sugar  by  ptyaHn,  the  greater  portion  is  converted 
into  maltose — only  a  small  portion  into  dextrose.  But  the  maltose 
formed  in  the  stomach  is  changed  to  dextrose  in  the  intestine.  If 
the  amylaceous  transformation  proceeds  normally  in  the  mouth  and 
stomach,  after  a  time — within  an  hour,  at  least — so  much  starch 
has  been  changed  into  achroodextrin,  maltose,  and  dextrose,  that 
the  addition  of  small  quantities  of  Lugol's  solution  to  the  filtered 
stomach  contents  no  longer  produces  any  changes  in  color.  The 
occurrence  of  a  purple  (erythrodextrin)  or  a  blue  color  (starch) 
shows  that  the  starch  transformation  has  been  incomplete.     This 


GASTRIC    JUICE.  47 

may  be  due  either  to  a  deficiency  of  ptyalin  or  to  a  rapidly  increasing 
acidity  or  hyperacidity  of  the  stomach. 

Ewald  states  that,  although  he  tested  a  large  number  of  patients 
for  the  fermentative  power  of  saliva,  he  never  found  a  saliva  that 
could  not  convert  starch  into  sugar.  This,  too,  when  he  tested  the 
salivary  secretion  of  patients  with  dental  caries,  angina,  diphtheria, 
and  carcinoma  of  the  tongue. 

From  the  above  it  is  evident  that  there  must  be  two  stages  of 
gastric  digestion,  (i)  an  amylolytic  and  (2)  a  proteolytic.  Having 
satisfied  ourselves  as  regards  the  fate  of  the  starches,  let  us  proceed 
to  study  proteolytic  digestion,  or  conversion  of  proteids,  gelatins, 
fibrins,  elastin,  etc. 

Gastric  Juice. — Hydrochloric  Acid. — The  secretion  of  the  stomach 
is  a  complex  fluid,  clear,  colorless,  and  of  acid  reaction;  it  has  only 
one-half  per  cent,  of  solid  ingredients.  The  amount  secreted  in 
twenty-four  hours  is  about  1 600  gm.  Its  chief  constituent  is  hydro- 
chloric acid,  which  it  contains  in  the  amount  of  o.i  to  0.22  per  cent, 
(one  to  two  per  thousand).  This  degree  of  acidity  is  not  reached 
at  once,  but  gradually ;  at  the  beginning  and  end  of  stomach  digestion 
the  percentage  of  HCl  is  considerably  less.  Besides  the  HCl,  gastric 
juice  contains  two  unorganized  ferments,  pepsin  and  rennin  (or 
chymosin). 

Hydrochloric  acid  acts  in  six  different  ways,  all  of  which  are  of 
great  significance  for  the  normal  progress  of  digestion. 

1 .  HCl  acts  as  an  antizymotic  or  antiseptic,  destroying  pathogenic 
organisms  and  preventing  abnormal  fermentations.  This  anti- 
bacterial effect  extends  even  into  the  duodenum. 

2.  HCl  has  the  power  to  convert  the  proenzymes  of  the  gastric 
glands  (pepsinogen  and  rennin  zymogen)  into  active  ferments  in  a 
very  short  time  (according  to  Tangley,  in  one  minute). 

3.  This  gastric  acid  possesses  a  certain  regulating  influence  on  the 
progress  of  peristalsis. 

4.  HCl  transforms,  with  the  aid  of  pepsin,  albuminous  bodies  into 
peptones,  gelatin  into  gelatin  peptone,  elastin  into  elastin  peptone. 
But  in  reality  the  pepsin  is  the  main  or  chief  agent  in  these  trans- 
formations, as  the  HCl  can  be  effectively  substituted  by  nitric,  phos- 
phoric, oxalic,  sulphuric,  lactic,  and  butyric  acids. 

5.  By  HCl  cane  sugar  is  changed  to  invert  sugar  (dextrose  and 
levulose).  This  property  is  also  ascribed  to  a  number  of  bacteria 
that  can  invert  cane  sugar,  although  after  a  longer  tithe. 


48  PHYSIOLOGY   OF    DIGESTION. 

6.  HCl,  finally,  is  instrumental  in  bringing  into  solution  the  soluble 
calcium  and  magnesium  salts,  introduced  in  the  food. 

Concerning  the  origin  and  derivation  of  the  hydrochloric  acid, 
we  unfortunately  have  nothing  but  speculation.  No  free  acid  occur- 
ring in  the  blood  or  lymph,  it  is  rational  to  conclude  that  it  is  pro- 
duced in  the  secreting  (oxyntic)  cells  of  the  gland-ducts.  It  seems 
probable  that  the  acid  is  derived  from  the  neutral  chlorids  of  the 
blood,  which  are  in  some  way  decomposed,  the  chlorin  uniting  with 
hydrogen  to  form  HCl.  The  acid  is  secreted  at  the  gastric  mucosa, 
while  the  base  remains  behind,  and  probably  passes  back  into  the 
blood.  This,  in  a  way,  explains  the  increased  alkaUnity  of  the  blood 
and  the  decrease  of  acidity  of  the  luine  after  meals,  the  retiim  of 
basic  substances  into  the  circulation  naturaUy  having  such  an  effect. 
According  to  Heidenhain,  a  free  organic  acid  is  secreted  by  the  cells 
(oxyntic),  which  then  decomposes  the  chlorids.  According  to  Maly, 
the  HCl  is  the  result  of  a  reaction  between  the  phosphates  and  chlorids 
of  the  blood,  as  expressed  in  the  following  two  equations: 

NaH^PO^  ^  NaCl  =  NajHPO^  +  HCl  or 
3CaCl,  -f-  2Na2HPO^  =  Ca^iFO^)^  +  4NaCl  +  2HCI. 

What  is  known  thus  far  of  the  specific  action  of  hving  cells  en- 
forces the  impression  here,  that,  as  in  other  chemical  processes  not 
yet  understood,  vital  phenomena  are  difficult  to  express  in  chemical 
formulas. 

The  gastric  secretion  is  dependent  upon  innervation  through  the 
vagi.  When  the  vagi  are  cut  through  in  dogs  (the  right  one  in 
such  a  manner  as  to  leave  the  inferior  laryngeal  and  the  cardiac 
rami  intact — i.  e.,  below  the  point  at  which  these  nerves  are  given 
off,  so  as  to  preserve  the  sensibility  and  motility  of  the  larynx  and 
the  cardiac  innervation),  the  secretion  of  gastric  juice  ceases  (J.  P. 
Pawlow,  "Die  Arbeit  der  Verdauungsdrusen"  [original  in  Russian], 
1898,  p.  72). 


PEPSINOGEN   AND    PEPSIN.  49 


CHAPTER  V. 

PEPSINOGEN  AND    PEPSIN.— RENNIN    ZYMOGEN    AND 

RENNIN.— FAT   SPLITTING   FERMENT    OF   THE 

STOMACH.— INTESTINAL  DIGESTION.— 

DUODENAL  INTUBATION. 

It  should  not  be  understood  that  all  combinations  of  the  gastric 
juice  with  albumins  are  at  once  peptones;  like  the  starches,  the 
proteids  reach  their  end  stage  of  gastric  digestion  by  a  series  of  dis- 
tinct intermediate  stages.  These  are  (i)  proteid,  (2)  acid  albumin 
or  syntonin,  (3)  propeptone  or  hemialbumose,  and  (4)  peptone. 
Besides  forming  peptones  out  of  albumins,  pepsin  deprives  gelatin 
of  its  property  to  coagulate,  or  rather  to  gelatinize,  and  forms  gelatin 
peptones  out  of  it.  Peptones  are  derived  from  egg,  serum,  and  plant 
albumins,  gelatin,  meat,  fibrin,  casein,  etc. 

The  steps  in  peptic  digestion  may  be  made  more  intelligible  by 
the  following  schema,  modified  from  that  of  Neumeister  (' '  Lehrbuch 
d.  physiol.  Chemie,"  1893,  p.  187) : 

Proteid 


Syntonin 


Primary  proteoses, Protoproteose  Heteroproteose. 

Secondary  proteoses, Deuteroproteose  Deuteroproteose. 

Amphopeptones,      Peptone  Peptone. 

No  other  mineral  acid  gives  so  good  results  with  pepsin  as  HCl, 
which  can  form  pepsin  from  pepsinogen  in  the  shortest  time.  It 
is  useful  to  be  able  to  test  for  propeptone  formation.  In  normal 
digestion,  one  hour  after  the  test-breakfast,  propeptone  is  present 
only  in  traces,  or  usually  is  not  to  be  detected  at  all;  but  in  abnor- 
mally slow  digestion  it  is  still  abundant  at  that  period. 


50  PEPSINOGEN   AND    PEPSIN. 

The  most  expedient  method,  up  to  present  date,  is  by  means  of 
the  biuret  reaction.  In  this  reaction  a  dilute  solution  of  cupric  sul- 
phate is  added  to  stomach  contents  in  the  cold,  and  a  few  drops  of 
potassium  hydroxid  added  sufficient  to  make  the  solution  alkaline; 
an  intense  red  color  results.  Cupric  sulphate  and  KOH,  added  to 
ordinary  albumin  and  syntonin,  without  warming,  produces  a  bluish 
violet,  which  must  be  distinguished  from  the  purple-red  of  biuret. 

The  more  marked  the  propeptone  reactions  are,  the  less  the  pep- 
tone which  has  been  formed  and  eventually  removed  from  the  stom- 
ach. We  can  approximately  estimate  the  amount  of  the  peptone 
by  the  intensity  of  the  biuret  reaction  if  we  always  use  the  same 
quantities  of  stomach  contents,  caustic  potash,  and  cupric  sulphate, 
and  compare  it  with  the  reaction  given  with  a  peptone  solution  of 
known  strength.  One  hour  after  an  Ewald  test-breakfast,  given  to 
a  person  with  normal  digestion,  propeptone  is  either  not  found  at 
all  or  only  in  traces;  but  in  abnormally  weak  or  slow  digestion, 
propeptone  is  still  abundant  at  that  period.  Peptone  gives  the  same 
pink,  purple-red  color  with  the  biuret  reaction  as  propeptone.  In 
estimating  the  rate  of  proteolysis  in  the  stomach,  the  biuret  reaction 
will  not  permit  us  to  distinguish  between  these  two  bodies;  the 
only  differentiation  possible  is  by  precipitation  of  the  propeptone 
in  the  following  manner:  The  stomach  filtrate  is  carefully  neutral- 
ized, an  equal  quantity  of  common  salt  solution  is  added,  and  then  a 
few  drops  of  concentrated  acetic  acid.  A  precipitate  will  be  pro- 
peptone, which  can  be  filtered  off  and  weighed;  any  red  biuret  re- 
action after  this  separation  must  be  due  to  peptone. 

In  order  to  determine,  in  a  given  specimen  of  stomach  contents, 
whether  the  pepsin  or  HCl  is  present  in  too  great  or  too  small  a  quan- 
tity, one  proceeds  in  the  following  manner : 

Pour  ID  c.c.  filtered  stomach  contents  into  four  test-tubes  and 
number  them  Nos.  i,  2,  3,  4.  To  No.  i,  nothing  further  is  added; 
to  No.  2,  enough  HCl  to  make  a  solution  of  2  to  3  per  thousand  (this 
can  be  accomplished  by  adding  one  or  two  drops  of  officinal  HCl, 
U.  S.  Pharm.,  to  10  c.c.  filtrate);  to  No.  3,  0.2  to  0.5  gm.  (gr.  iij  to 
gr.  vij)  of  pure  pepsin  is  added,  and  to  No.  4  both  PICl  and  pepsin 
are  supplied. 

A  small  disc  of  egg-albumen  (which  is  prepared  by  cutting  boiled 
egg-albumen  into  lamellae  of  uniform  thickness  with  a  microtome 
and  punching  out  equal  circles  by  a  cork-borer)  is  added  to  each 
test-tube,  and  they  are  then  put  in  the  incubator  at  100°  F.     The 


RENNIN.  51 

rate  at  which  the  albumin  is  dissolved  will  tell  us  whether  the  fil- 
trate was  perfect  as  regards  the  requisite  amount  of  pepsin  and  HCl, 
whether  pepsin  alone,  or  HCl  only,  or,  finally,  whether  both  were 
necessary.  In  this  way  we  can  discover  which  factor  is  at  fault.  In 
the  human  stomach  the  formation  of  peptone  remains  at  a  certain 
percentage  by  the  removal  or  absorption  of  peptones  over  that 
amount,  and  also  it  would  seem  by  an  inhibiting  influence  which  a 
certain  percentage  of  peptone  has  over  the  proteolytic  process  in 
retarding  or  suspending  it.  As  this  can  not  be  imitated  in  a  test- 
tube, — i.  e.,  the  absorption  of  ready-formed  peptones, — a  seemingly 
delayed  digestive  process  of  egg-albumen  discs  in  the  test-tubes 
may  in  reality  be  due  to  a  very  active  stomach  filtrate.  The  amount 
of  HCl  and  the  amount  of  pepsin  must  be  in  definite  relation  to  each 
other.  Excess  of  HCl  is  as  much  of  a  check  as  insufficiency  of  this 
acid. 

Rennin,  chymosin,  or  pexin,  the  second  gastric  ferment,  pro- 
duces a  light,  not  very  cohesive,  coagulation  of  milk.  This  coagu- 
lation is  a  characteristic  cake  of  casein  floating  in  clear  serum,  more 
dense,  not  lumpy,  more  cohesive  coagulation,  than  that  produced 
by  acids.  This  ferment  is  a  constant  constituent  of  the  stomach 
contents,  just  as  pepsin  and  pepsinogen.  With  a  complete  absence 
of  the  rennin  and  its  proenzyme,  one  can  with  certainty  conclude 
that  the  case  is  one  of  atrophy  of  the  gastric  mucosa. 

The  demonstration  of  rennin  ferment  is  carried  out  in  the  follow- 
ing manner:  Ten  c.c.  of  raw,  unboiled  milk  are  placed  in  the  incu- 
bator with  2.5  drops  of  stomach  filtrate.  If  rennin  is  present,  the 
characteristic  milk  coagulation  will  occur  in  a  variable  time  (one 
minute  to  several  hours,  according  to  the  quantity  of  ferment).* 

Occasionally,  rennin,  the  perfect  ferment,  is  not  contained  in  the 
stomach  contents,  while  at  the  same  time  rennin  zymogen  (pexino- 
gen  chymosinogen)  is  present.  This  is  demonstrated,  according 
to  Hammarsten,  by  adding  to  the  mixture  just  described  2  c.c.  of 
a  concentrated  solution  of  calcium  chlorid,  CaClj. 

If  a  rennin  coagulum  occurs,  it  follows  that  rennin  zymogen  is 
present,  but  not  the  perfect  ferment.  For  these  tests,  raw  milk 
only  can  be  used,  as  it  coagulates  ten  times  as  rapidly  as  boiled  milk. 
Jaworski  has  pointed  out  that  in  cases  where  tests  for  rennin  and 

*  The  presence  of  peptone  delays  the  clotting  of  milk  by  chymosin  (E.  Gley,  "  Compt. 
Rend.,"  1896,  591.  A.  Edmunds,  "Journ.  Physiol.,"  .xix,  474,  1896.  F.  S.  Locke, 
"Journ.  Experim.  Med.,"  vol.  ii,  p.  493). 


52  FAT   SPLITTING  Fe;rmENT  OP  THS   STOMACH. 

rennin  zymogen  are  both  negative,  it  is  advisable  to  try  pouring  a 
0.3  per  cent,  to  0.6  per  cent,  solution  of  hydrochloric  acid  into  the 
stomach,  to  see  whether  this  HCl  may  not  be  able  to  awaken  a  se- 
cretion of  rennin;  this  should  especially  be  done  before  making  the 
diagnosis  of  complete  atrophy  of  the  mucosa.* 

The  Fat  Splitting  Ferment  of  the  Stomach. — Gastric  Lipase. 
— In  addition  to  the  functions  already  described  the  gastric  mucosa 
has  the  power  of  splitting  up  neutral  fats  into  glycerin  and  fatty 
acids.  Although  I  had  frequently  observed  this  chemical  change 
in  artificial  digesting  mixtures  made  from  human  gastric  juice,  I 
was  inclined  to  attribute  the  fat  splitting  effect  to  bacteria.  But 
in  1900  Franz  Volhard  ("Zeitschr.  f.  klin.  Med.,"  1901,  Bd.  XLii, 
Heft.  V  u.  vi)  suggested  filtering  the  gastric  juice  through  a  Pasteur 
or  clay  filter.  After  thus  removing  all  bacteria  the  gastric  juice 
still  showed  the  fat  splitting  effect,  so  that  it  seemed  very  probable 
there  was  indeed  a  fat  splitting  ferment  present  in  the  gastric  juice 
of  human  beings.  These  experiments  of  Volhard  (see  also  "Munch- 
ener  med.  Wochenschr.,"  1900,  Heft,  v  u.  vi)  I  have  repeated  with 
finely  emulsified  milk  and  egg  fat,  and  human  gastric  juice  obtained 
after  drawing  test  meals.  When  finely  emulsified  egg  and  milk  fat 
are  carefully  neutralized  and  brought  into  the  human  stomach  and 
drawn  out  again  after  from  one  to  two  hours,  it  will  not  be  regained 
as  neutral  fat,  but  approximately  sevent}'-  per  cent,  of  it  will  have 
been  split  up  and  appear  as  fatty  acids.  It  was  possible  to  confirm 
Volhard's  results  in  my  private  laboratory;  viz.,  that  the  fat  splitting 
ferment  is  capable  of  passing  through  a  Pasteur  filter,  and  that  the 
fat  sphtting  effect  may  be  obtained  with  human  gastric  juice  that 
has  been  thus  freed  from  bacteria,  and  when  the  digestive  process 
is  carried  on  in  a  test-tube. 

A  difficulty  was  encountered,  however,  in  the  efforts  to  steriHze 
the  egg  and  milk  fat,  and  also  in  the  fact  that  the  yolk  of  egg  and  even 
normal  milk  may  contain  free  fatty  acids.  The  bacteria  in  yolk  of 
egg  and  milk  fat  can  be  completely  removed,  however,  and  the 
amount  of  fatty  acids  in  these  substances  can  be  determined  prior 
to  the  experiment.  Klemperer  and  Scheurlen  ("/^eitschr.  f.  klin. 
Med.,"  Bd.  xv,  S.  370)  had  called  attention  to  the  occurrence  of  fatty 
acids  in  excessive  gastric  fermentations  occurring  in  dilated  stomachs, 

*The  word  "  pexine  "  for  this  ferment,  while  etymologically  and  historically  pre- 
ferable, has  the  serious  disadvantage  of  sounding  very  much  like  the  word  "pepsin," 
when  rapidly  spoken.      The  word  "  chymosin  "  avoids  this  possible  confusion. 


FAT   SPLITTING   FERME;nT   OF   THE    STOMACH.  53 

but  Marcet  ("The  Med.  Times  and  Gazette,"  new  series,  1858,  vol. 
XVII,  p.  210)  was  the  first,  I  think,  to  call  attention  to  the  occurrence 
of  a  fat  splitting  ferment  in  the  normal  stomach.  Later  on,  Cach 
("Du  Bois'  Archiv,"  1880,  p.  323)  and  Ogata  ("Du  Bois'  Archiv," 
1 88 1,  p.  515)  experimented  in  Lud wig's  laboratory  and  ascertained 
that  the  stomach  of  a  living  animal  has  the  power  of  splitting  up 
neutral  fats  to  a  certain  degree.  The  observations  of  Klemperer 
and  Scheurlen,  who  asserted  that  one  to  two  per  cent,  of  oil  could  be 
split  up  under  normal  conditions  in  two  hours,  but  that  in  a  dilated 
stomach  six  per  cent,  of  oleic  acid  would  be  produced  from  neutral 
oil,  were  conducted  in  the  clinic  of  von  Ley  den. 

In  a  recent  publication  Franz  Volhard  has  investigated  the  physi- 
ology of  this  fat  splitting  ferment  in  a  very  thorough  manner  ("Ueber 
das  fettspaltende  Ferment  des  Magens,"  "  Habilitationsschrif t" ; 
"Zeitschr.  f.  khn.  Med.,"  Bd.  xuii,  Heft,  v  u.  vi);  he  discovered 
that  the  glycerin  extract  of  a  finely  cut  up  pig  stomach  also  will  con- 
tain this  fat  splitting  ferment,  and  that  it  is  contained  in  the  extract 
of  the  fundus  in  much  more  concentrated  form  than  in  the  extract 
of  the  pyloric  part.  This  is  analogous  to  the  local  distribution  of 
the  cells  which  produce  the  pepsinogen  and  chymosinogen  (rennet). 
The  fat  splitting  function  of  this  gastric  ferment  is  not  restricted  to 
natural  emulsions,  like  milk  and  egg  yolk,  but  also  it  extends  to  ar- 
tificial emulsions.  The  intensity  of  the  reaction  depends  less  upon 
the  nature  of  the  fat  than  upon  the  fineness  of  the  emulsion  and  the 
degree  to  which  the  emulsion  can  be  moistened  by  water}'-  fluids. 
In  his  last  publication,  Volhard  has  studied  the  behavior  of  this  fer- 
ment toward  acids  and  alkalis.  These  studies  are  significant  for 
the  conduct  of  the  ferment  during  hyperchlorhydria  on  the  one 
hand,  and  also  for  the  fate  of  the  ferment  after  the  gastric  chyme 
leaves  the  stomach  and  reaches  the  alkaline  duodenum.  More- 
over, if  the  new  ferment  showed  a  greater  resistance  alkali  than 
the  pepsin  and  chymosin  which  are  destroyed  by  minimum  quan- 
tities of  the  alkali,  it  was  conceivable  that  it  might  by  this  manner 
be  freed  from  the  other  ferments  and  thereby  the  action  of  pepsin 
might  possibly  be  excluded.  His  experiments,  however,  showed 
that  this  separation  of  the  ferments  was  not  possible. 

Among  the  facts  ascertained  by  this  observer  are  the  following: 
I.  The  glycerin  extract  of  the  gastric  mucosa  is  not  sensitive  to 
alkali,  but  the  ferment  as  contained  in  the  gastric  juice  obtained 
from  drawn  gastric  contents  is  very  sensitive  to  alkali. 


54  ^^^   SPLITTING   FERMENT    OE   THE    STOMACH. 

2.  The  fat  splitting  ferment  of  the  gastric  juice  is  more  resistant 
to  HCl  than  that  of  the  glycerin  extract  of  gastric  mucosa. 

3.  The  gastric  juice  contains  the  perfect  fat  splitting  ferment; 
the  extract  of  mucosa  contains  its  zymogen. 

4.  The  adipolytic  effect  does  not  increase  proportional  to  the 
time,  but  at  irregular  intervals. 

5.  The  reaction  is  incomplete;  only  a  certain  percentage  of  the 
neutral  fat  present  is  split  up,  independently  of  the  total  quantity 
present. 

6.  Schiitz  ("Zeitschr.  f.  physiol.  Chemie,"  ix,  S.  577,  1885)  an- 
nounced a  law  according  to  which  the  amount  of  digestive  products 
is  not  proportional  to  the  amount  of  ferments,  but  to  the  square  root 
of  the  amount  of  the  ferments.  This  law  has  been  confirmed  by 
Borissow  (C.  Paw  low,  "Die  Arbeit  der  Verdauungsdriisen,"  S.  32). 
Pawlow  and  Walther  have  confirmed  this  law  for  all  fermentative 
processes  of  the  digestive  canal — peptic,  tryptic,  amylolytic,  and 
styptic;  and  Volhard  has  discovered  that  this  law  (the  digestive 
products  are  proportional  to  the  square  root  of  the  amount  of  the 
ferments ;  in  other  words,  one  has  to  have  four  times  as  much  of  the 
ferment  to  obtain  twice  as  much  of  the  end  product)  is  applicable 
to  this  new  fat  splitting  ferment.  For  instance,  if  one  digestive 
mixture  will  digest  two  milligrams  of  egg-albumen,  and  the  other 
three  milligrams,  then  the  relative  quantities  of  pepsin  in  these 
liquids  are  not  expressed  by  the  figures  2  and  3,  but  by  the  squares 
of  these  figures;  i.  e.,  4  and  9. 

7.  In  achylia  gastrica  the  secretion  of  the  fat  splitting  ferment  is 
much  reduced,  analogous  to  that  of  the  pepsin  and  chymosin  pro- 
duction. 

8.  Excessive  hyperacidity  inhibits  the  fat  splitting  effect  in  the 
stomach. 

It  was  also  determined  in  these  experiments  that  very  strong 
concentrations  of  acid  or  alkali  may  in  themselves  effect  the  produc 
tion  of  acids  from  egg  yolk.  Such  concentrations  of  acid  and  alkali 
were  not  of  import  for  these  experiments,  and  it  is  probable  that  the 
acids  were  not  derived  from  the  fats,  but  from  the  egg-albumen.  No 
matter  how  much  neutral  fat  is  put  in  the  artificial  digestive  mix- 
ture, or  in  the  stomach,  this  fat  splitting  ferment  of  the  stomach — 
for  which  I  would  suggest  the  name  "gastric  lipase" — ceases  to  act 
when  a  certain  percentage  of  its  digestive  product  has  been  reached. 
This  is  analogous  to  the  conduct  of  the  other  digestive  ferments. 


PHYSIOLOGY    OF    INTESTINAL   DIGESTION.  55 

although  Volhard  does  not  regard  this  inhibition  as  due  to  the  fatt}^ 
acids,  as  these  remain  insoluble. 

It  is  interesting  to  note  that  a  certain  sensitiveness  of  gastric 
lipase  to  HCl  exists,  because  this  might  be  interpreted  as  an  antag- 
onistic action  between  pepsin  HCl  and  lipase.  It  is  well  known, 
from  the  experiments  of  Pawlow,  that  fats  inhibit  the  secretion  of 
pepsin  HCl,  thereby  insuring  a  proper  medium  for  the  action  of  gas- 
tric lipase.  An  artificial  gastric  juice,  which  is  prepared  according 
to  the  suggestion  of  Pawlow  {loc.  cit.),  has  become  a  commercial 
article  in  Germany,  under  the  name  of  "gasterine."  It  does  not  con- 
tain any  fat  splitting  ferment.  As  this  gastric  juice  is  made  from 
the  stomach  of  the  dog,  and  presents  a  very  high  total  acidity  (135) 
and  a  large  amount  of  free  HCl  compared  to  the  human  gastric 
juice,  it  is  expedient  to  always  work  with  the  latter  in  testing  for 
gastric  lipase.  As  the  gastric  lipase  is  destroyed  by  very  small  quan- 
tities of  free  alkali,  it  is  probable  that  this  fat  splitting  ferment  is 
normally  destroyed,  together  with  the  pepsin  and  chymosin,  by  the 
alkaline  pancreatic  juice  when  the  gastric  chyme  reaches  the  duo- 
denum. When  the  pancreas  is  extirpated  or  its  duct  tied  (Min- 
kowski, Abelmann,  Vaughan,  etc.),  a  certain  amount  of  fat  splitting 
ferment  has  been  observed  in  the  contents  of  the  intestine.  This 
was  attributed  to  the  intestinal  bacteria.  But  under  such  circum- 
stances it  must,  in  the  light  of  our  present  knowledge,  be  assigned 
to  the  action  of  gastric  lipase,  which  continues  to  act  in  the  intestine 
under  such  conditions. 

Gastric  lipase  is  not  destroyed  in  normal  gastric  juice  at  room 
temperature,  and  can  thus  be  preserved  for  several  days,  but  in  the 
incubator  it  decomposes,  in  neutral  as  well  as  in  acid  solution. 

The  Physiology  of  Intestinal  Digestion. — Our  knowledge  of 
the  digestive  processes  in  the  intestine  is,  from  a  physiological  as 
well  as  from  a  pathological  point  of  view,  defective;  at  times,  con- 
tradictory. Concerning  gastric  digestion  we  are  much  better  in- 
structed, because  here  the  processes  are  simpler,  and  material  for 
investigation  can  be  more  easily  obtained.  The  stomach-tube 
supplies  us  without  difficulty  with  gastric  contents,  but  hitherto  all 
intestinal  contents  of  human  beings  have  been  obtained  from  rare 
cases  of  intestinal  fistulae,  for  the  feces  give  no  constant  and  reliable 
information  of  the  digestive  actions  in  the  smaller  intestine. 

The  earliest  investigations  of  intestinal  contents  were  made  in 
1662  by  Regnier  de  Graaf,  who  made  experimental  fistulae  into  the 


56 


PHYSIOLOGY    OF    INTESTINAL   DIGESTION. 


intestinal  canal  of  animals.  It  is  a  curious  historical  fact  that  this 
intestinal  experiment  antedated  the  first  investigations  of  stomach 
contents,  which  were  carried  on  in  1752  by  Reaumur.  So  up  to 
the  present  time  there  was  no  prospect  of  getting  a  better  insight 
into  the  physiology  of  intestinal  digestion  until  a  method  for  intu- 
bating the  duodenum  in  the  living  human  subject  was  devised  by 
the  author. 

This  method,  which  is  described  in  the  "Johns  Hopkins  Hospital 
Medical  Bulletin"  for  April,  1895,  and  also  in  Boas'  "Archives  for 


7 


Fig.  5.— Apparatus  for  Obtaining  Intestinal  Contents. 


Digestive  Diseases,"  volume  11,  page  85,  consists,  in  the  first  place, 
of  the  introduction  of  a  thin,  elastic  rubber  bag  into  the  stomach. 
This  bag,  when  folded  over  a  tube  which  runs  through  it,  does  not 
occupy  as  much  space  as  an  ordinary  stomach-tube,  and  has  the 
exact  shape  of  the  human  stomach  when  it  is  distended  by  blow- 
ing it  up  within  that  organ,  to  which  it  fits  itself  exactly, — and  is 
closely  applied  to  the  gastric  walls. 

The  intragastric  bag  is  distended  by  the  pressure  apparatus  shown 
in  figure  6.  The  graduated  bottle  (A)  is  full  of  water  and  elevated 
above  the  bottle  (B),  which  is  empty  and  also  graduated. 


DUODENAL   INTUBATION. 


57 


The  stomach-shaped  bag  (C),  when  it  reaches  the  stomach,  is 
connected  with  the  lower  empty  bottle,  B.  Then  the  stop-cock 
connecting  A  with  B  is  opened,  and  the  water  runs  from  A  into  B, 
displacing  the  air  in  B,  which  distends  the  bag  C,  within  the  stomach, 
filling  it  entirely.  As  is  observable  on  this  bag,  a  guide  is  contained 
in  it,  running  along  the  dotted  line  parallel  to  the  lesser  curvature. 
In  this  guide  the  duodenal  tube  is  inserted,  lubricated  with  oil  before 
the  bag  is  pushed  into  the  stomach.  This  tube  is  provided  with 
very  thick  walls,  by  virtue  of  which  it  is  not  easily  kinked  or  bent 
upon  itself. 


Fig.  6.— Pressure  Bottles  for  Distending  the  Intragastric  Bag  during  Duodenal 

Intubation. 


The  relation  of  the  thickness  of  the  walls  to  the  diameter  of  the 
lumen  is  shown  in  the  cross-section  of  figure  5.  When  the  intra- 
gastric bag  is  distended,  it  fills  the  stomach  entirely.  The  duo- 
denal tube  lies  in  its  sheath  or  guide,  and  on  being  pushed  onward 
from  the  mouth,  it  is  not  possible  for  it  to  go  anywhere  else  except 
through  the  pylorus  into  the  duodenum.  In  the  illustrations  it  can 
be  seen  that  the  bag  is  not  distended  by  the  duodenal  tube,  but  a 
separate,  very  small  tube  runs  down  the  esophagus,  ending  in  the 
bag,  serving  the  purpose  of  its  distention.  Both  tubes  together  do 
not  occupy  as  much  space  as  an  ordinary  stomach-tube. 


58  DUODENAL   INTUBATION. 

A  description  of  this  method  is  considered  essential  because  it 
seems  to  be  destined  to  bring  our  knowledge  of  the  physiology  and 
pathology  of  the  intestines  upon  a  basis  of  ascertained  facts;  we 
can  at  any  time  thereby  obtain  the  contents  of  the  intestine,  and 
the  gut  may  in  any  of  its  parts  be  reached  with  safety. 

After  known  test-meals,  it  is  possible,  after  they  have  passed  from 
the  stomach  into  the  duodenum,  to  draw  out  samples  from  this 
part  and  subject  them  to  analysis.  By  alternately  distending  any 
part  with  air  or  water  we  will  be  enabled  to  locate  the  part  by  the 
percussion  sound  on  the  outside  of  the  abdomen,  and  the  distance 
it  is  located  from  the  mouth  can  be  seen  from  the  length  of  tube 
introduced. 

Small  electric  lamps  may  be  introduced  into  the  duodenum  as 
they  are  into  the  stomach,  aijd  the  location  and  condition  recognized 
by  electrodiaphany. 

Hitherto,  in  all  experiments  on  this  subject  it  has  been  impossible 
to  obtain  either  the  pancreatic  or  biliary  secretion  in  a  pure  con- 
dition ;  this  is  due  to  the  fact  that  both  the  pancreatic  and  the  com- 
mon gall-duct  empty  into  the  descending  portion  of  the  duodenum 
very  near  each  other. 

In  May,  1897,  we  had  under  observation  a  female  patient  who 
had  suffered  repeated  attacks  of  biliary  colic.  At  times  she  passed 
small  stones  without  giving  her  much  pain — at  least  they  were 
found  in  the  stools  without  having  given  her  any  colic.  She  was 
willing  to  undergo  an  operation  to  be  relieved.  Through  the  com- 
paratively thin  abdominal  walls  we  were  able  to  feel  numerous 
stones  in  the  gall-bladder.  She  consented  to  an  attempt  at  intuba- 
tion of  the  duodenum  to  determine  whether  there  was  any  bile 
secreted.  The  duodenum  was  entered  without  difficulty,  and 
cleansed  by  running  in  and  aspirating  out  distilled  warm  water. 
Twelve  hours  afterward,  no  food  having  been  taken  in  the  mean 
while,  the  duodenum  was  again  intubated  according  to  our  method, 
and  washed  with  100  c.c.  of  warm  distilled  water. 

On  being  aspirated,  the  water  was  still  clear,  but  viscid  and  sticky, 
similar  to  a  solution  of  egg-albumen.  It  contained  no  bile-pigments 
nor  cholesterin,  and  was  free  from  taurocholates  and  glycocholates. 
It  was  colorless  and  odorless,  and  seemed  very  rich  in  some  form  of 
albumin.  That  it  was  a  solution  of  pancreatic  juice  was  proved  by 
its  digesting  fibrin  and  serum-albumin. 

The  juice  obtained  in  this  manner  digested  from  eighty-five  to 


the;  pancreas.  59 

ninety-five  per  cent,  of  Merck's  dried  serum-albumin  in  the  diges- 
torium  at  100°  F.  in  two  hours.  The  amylolytic  and  fat-decompos- 
ing property  of  the  juice  was  determined  in  a  similar  manner.  One 
is  therefore  justified  in  concluding  that  in  this  case  the  pancreatic 
juice  was  obtained  almost  pure,  as  there  were  no  bile  elements  con- 
tained in  it,  the  bile  being  prevented  from  entering  the  duodenum  by 
a  calculus  or  catarrhal  occlusion  in  the  common  duct.  As  there  are 
also  pancreatic  calculi,  or  occlusions  of  the  duct  by  neoplasm  or 
catarrhal  swelling,  it  is  conceivable  that  we  may  yet  be  able  to  obtain 
the  bile  in  a  pure  condition,  and  free  from  pancreatic  juice,  from 
the  human  subject,  without  operation. 

The  secretions  of  Brunner's  and  Tvieberkiihn's  glands  will,  how- 
ever, always  constitute  an  admixture  of  these  juices. 

The  Pancreas :  its  Secretion  and  Pancreatic  Digestion. — 
In  1846  Claude  Bernard  made  the  first  scientific  and  fundamental 
investigation  concerning  the  pancreatic  secretion.  Later  on  Kiihne, 
Bidder  and  Schmidt,  Corvisart,  Heidenhain,  and  others  amplified 
these  results. 

Its  secretion,  as  Bernard  first  observed,  is  dependent  upon  diges- 
tion, and  is  a  clear,  colorless,  and  odorless  fluid,  very  alkaline,  and 
so  rich  in  albumin  that  it  solidifies  on  boiling.  Zawardsky  had 
opportunity  of  analyzing  the  normal  human  pancreatic  secretion  in 
a  case  of  pancreatic  fistula,  which  remained  behind  after  removal  of 
a  tumor.  According  to  his  analysis  it  contained  86.4  per  cent, 
water,  13.25  organic  substances;  among  the  latter  are  9.2  proteid 
bodies  and  0.83  extractive  substances,  soluble  in  alcohol;  lastly, 
0.34  per  cent,  salts. 

The  chyme  which  passes  into  the  duodenum  from  the  stomach 
comes  under  the  influence  of  formed  or  organized  and  unformed 
or  unorganized  ferments.  The  formed  or  organized  ferments  are 
represented  by  bacteria,  which  bring  about  carbohydrate  fermenta- 
tion, mostly  in  upper  bowel,  and  proteid  putrefaction,  mostly  in 
lower  bowel. 

The  unorganized  ferments  are  contained  in  the  pancreatic  secre- 
tion, the  bile,  and  in  the  succus  entericus.  The  most  important 
constituents  of  the  pancreas  are  three  ferments  or  enzymes:  (i)  an 
amylolytic,  (2)  a  proteolytic,  and  (3)  a  fat-splitting  ferment  (adipo- 
lytic).  ' 

According  to  W.  G.  Halliburton  and  T.  G.  Burton  ("Journal  of 
Physiology,"  vol.   xx,   p.    106),   pancreatic  juice  possesses  a  milk- 


6o  THS   PANCREAS. 

precipitating  substance,  causing  at  35°  to  45°  C.  a  granular  precip- 
itate in  milk,  but  there  is  no  solidification  until  the  milk  cools,  when 
it  sets  to  a  coherent  curd.  On  warming,  the  curd  is  broken  up, 
and  the  milk  resumes  its  granular  fluidity.  The  granular  precip- 
itate produced  by  pancreatic  juice  seems,  according  to  these  ob- 
servers, to  be  intermediate  between  casein  and  caseinogen. 

The  amylolytic  or  pancreas  diastase  is  very  similar  to  ptyalin  in 
its  action,  and  changes  boiled  starch  into  maltose  exceedingly  rapidly 
at  body  temperature.  In  addition,  small  quantities  of  dextrin  and 
grape  sugar  are  formed;  one  gm.  of  pancreatic  juice  from  a  dog  will 
invert  3.6  gm.  starch  into  sugar.  Cane  sugar  and  inulin  are  not 
affected  by  it.  According  to  Zweifel,  this  ferment  is  absent  in  the 
pancreas  of  new-born  children. 

The  fat-spHtting  ferment  of  the  pancreas  (also  called  steapsin), 
which  thus  far  has  not  been  obtained  in  a  pure  state,  breaks  up 
neutral  fats  into  fatty  acids  and  glycerin.*  This  process  occurs  very 
slowly,  however.  Berthelot  found  that  fifteen  grams  of  pancreatic 
secretion  of  the  dog  required  at  least  twenty-four  hours  to  break  up 
two  decigrams  of  monobutyrin  completely  into  butyric  acid  and 
glycerin.  The  fatty  acids  formed  during  this  transformation  com- 
bine with  alkalies  in  the  intestine  to  form  soaps,  which,  by  emulsi- 
fying other  fats,  assist  greatly  in  their  absorption.  In  the  laboratory 
it  always  requires  powerful  mechanical  action  to  effect  an  emulsion 
of  fats;  not  so  in  the  intestine,  where  it  is  evidently  accomplished 
with  great  facility.  That  this  must  greatly  assist  in  fat  resorption 
is  evident  from  the  frequent  observation  that  after  disease  of  the 
pancreas  the  feces  become  very  rich  in  fat,  which  may  be  present 
in  so  large  an  amount  as  to  congeal  on  the  surface  of  the  stool. 

The  proteolytic  ferment  of  the  pancreas  has  been  called  trypsin 
by  Kiihne.  Digesting  boiled  blood-fibrin  with  pancreatic  juice,  he 
found  that  it  did  not  swell  up,  but  that  it  became  very  fragile,  and 
finally  liquefied.  As  we  take  in  all  our  albumin  in  a  boiled  or  roasted 
state,  which  becomes  peptone  in  the  stomach  and  not  soluble  albu- 
min, the  question  has  arisen:  Whence  do  we  derive  our  soluble 
native  albumin?     This  is  obtained  from  pancreatic  trypsin  digestion 

*  The  form  in  which  the  fats  are  uUimately  absorbed  from  the  intestine  is  still  a  matter 
of  hypothesis  (Schafer's  "Textbook  of  Physiology,"  vol.  I,  article  on  Fat  Absorption). 
The  emulsion  theory — i.e.,  absorption  as  natural  fat — and  the  solution  theory — i.e.,  absorp- 
tion as  fatty  acids  and  soaps — are  both  advocated  by  physiologists  of  prominence,  so  that 
no  exact  scientific  conclusion  in  favor  of  either  view  is  as  yet  possible. 


the;  pancreas.  6 1 

of  boiled  albuminous  bodies,  which  changes  them  to  albumin  soluble 
in  water,  or  at  least  in  a  weak  saline  solution,  from  which  they  can 
be  precipitated  by  heat.  The  proteolytic  action  of  trypsin  takes 
place  best  in  an  alkaline  or  neutral  medium,  though  it  is  still  active 
in  faintly  acid  media. 

Among  the  bodies  formed  from  albumins  and  proteids  under  the 
influence  of  trypsin  are  a  globulin  that  is  insoluble  in  water,  hemi- 
peptone  and  antipeptone,  leucin,  tyrosin,  and  asparaginic  acid.  In- 
dol,  which  is  found  in  the  jejunum,  is  a  product  of  bacterial  action 
on  albumins.  A  chromogenic  body  has  been  described  by  Tiede- 
mann  and  Gmelin  which  has  received  the  name  tryptophan;  it  is  a 
result  of  advanced  albumin  decomposition.  Trypsin,  then,  to  sum 
up,  changes  proteids  to  peptones  and  soluble  albumins,  casein  to 
casein  peptones,  gelatin  to  gelatoses  and  gelatin  peptone,  and  elastin 
to  elastoses  and  elastin  peptones. 

In  animals  that  have  been  deprived  of  their  pancreas  by  opera- 
tion, only  forty-four  per  cent,  of  proteid,  fifty-seven  per  cent,  to 
seventy  per  cent,  of  carbohydrates,  and  no  fats  at  all,  were  absorbed, 
although  four-fifths  of  the  fats  was  split  up  into  fatty  acid  and 
glycerin. 

The  processes  of  tryptic  digestion  are  briefly  represented  in  the 
following  schema,  according  to  Neumeister: 

Proteid 


Deutero Albumose 


Amphopeptone 


Antipeptone  Hemipeptone 


Leucin  Tyrosin  Aspartic  acid         Tryptoplian 

Trypsin  produces  peptone  from  proteids  more  readily  than  does 
pepsin.  On  account  of  certain  diflferences,  chiefly  recognizable  in 
dialysis,  between  the  end  products  of  peptic  digestion  or  peptones 

5 


62  THE   BILE. 

and  those  of  tryptic  digestion,  the  name  of  tn-ptones  is  used  by  the 
author  in  reference  to  the  latter. 

The  principal  secretory  nerve  of  the  pancreas  is  the  vagus  (Paw- 
low,  I.  c,  p.  73). 

The  gastric  chyme  by  virtue  of  its  contained  HCl  stimulates  the 
pancreatic  secretion  reflexly  by  acting  on  the  duodenal  mucosa. 
Starch  is  no  exciter  of  pancreatic  secretion,  but  it  augments  the 
amount  of  amylopsin  contained  in  it.  Fat  is  a  marked  stimulant 
to  pancreatic  secretion  and  augments  its  amount  of  steapsin.  Solu- 
tions of  alkahne  and  neutral  salts  inhibit  the  action  of  the  pancreas. 
The  physiological  excitants  of  the  gastric  secretion  are  the  extrac- 
tives (bouillon),  while  acids,  fats,  and  even  water  are  the  physio- 
logical stimulants  to  pancreatic  secretion. 


CHAPTER  VI. 

THE  BILE.— THE  SUCCUS  ENTERICUS.— INTESTINAL 

FERMENTATION.— PUTREFACTION.— FORMED 

OR  ORGANIZED  FERMENTS. 

It  is  known  at  present  that  the  bile  exerts  no  chemical  effects 
upon  the  food  materials;  nevertheless,  its  presence  in  the  duodenal 
chyme  is  significant  on  account  of  its  alkaline  reaction  and  its  effect 
on  the  mucous  membrane.  The  most  important  function  of  the  bile 
is  the  excretion  of  metabolic  products  that  can  not  be  utilized  in 
the  organism. 

The  contents  of  the  gall-bladder  represent  a  concentrated  secre- 
tion; therefore  our  knowledge  of  the  physiological  action  of  the  bile 
depends  upon  the  discharge  of  biliary  fistulae.  The  bile  is  a  golden 
yellow,  at  times  olive-brown,  secretion;  it  is  never  of  a  green  color, 
but  generally  very  mucoid  and  stringy.  Its  alkaline  reaction  is 
due  mainly  to  carbonates  and  phosphates.  The  quantity  poured 
into  the  intestine  is  largest  in  the  first  hour  after  food  is  taken. 

Albumins  increase,  fats  diminish,  this  quantity,  while  sugar  and 
carbohydrates  appear  to  exert  no  influence  (Voit).  The  quantity 
secreted  in  twenty-four  hours  averages  from  500  to  600  c.c.  (Ranke, 
Wittich,   Hammarsten).     According  to   Phaff  and   Balch   ("Journ. 


THE    BIIvE.  63 

Experim.  Med.,"  vol.  11,  p.  59),  the  daily  quantity  was  514.3  c.c, 
and  the  greatest  quantity  may  be  secreted  at  any  time  of  the  day, 
and  stands  in  no  definite  relation  to  any  meal.  The  quantitative 
analyses  of  Hammarsten  have  given  the  following  results: 

Solid  materials, 1.62    to    3.52 

Water, 96.47     "  98.37 

Mucin  and  coloring  matter, 0.27     "  0,91 

Compounds  of  bile-acids  and  alkalies, ,    .  0.26    "  1.82 

Taurocholate, 0.052  "  0.203 

Glycocholate, 0.204  "  l-6i 

Fatty  acids, 0.024  "  0.136 

Cholesterin, 0.048  "  0.16 

Lecithin, 0.048  "  0.065 

Fat, o.o6r  "  0.095 

-Soluble  salts, 0.676"  0.887 

Insoluble  salts, 0.02     "  0.049 

At  times  a  diastatic  ferment  is  present  in  the  bile ;  it  is  not  a  specific 
constituent  (Neumeister),  but  appears  in  the  bile  like  the  diastatic 
ferment  which  appears  in  the  urine ;  it  seems  to  be  identical  with  the 
ptyalin  zymogen  of  the  pancreatic  juice. 

When  the  bile  is  prevented  from  entering  the  intestine,  albu- 
mins, gelatins,  and  carbohydrates  are  absorbed  in  a  normal  manner 
(Voit  and  J.  Munk),  but  the  digestion  of  fats  is  very  seriously  inter- 
fered with ;  a  normal  animal  resorbs  99  per  cent,  of  fats,  if  not  more 
than  150  to  200  grs.  are  given — i.  e.,  only  one  per  cent,  appears 
in  the  feces,  but  on  producing  an  experimental  fistula  conduct- 
ing the  bile  outward,  60  per  cent,  of  the  fats  are  not  utilized 
(Voit).  The  subjoined  is  a  synopsis  of  the  uses  and  functions  of 
the  bile: 

1.  Fats  are  brought  into  a  fine,  permanent  emulsion  by  bile,  just 
as  by  pancreatic  juice. 

2.  Bile  assists  the  fat-splitting  effect  of  pancreatic  juice  (Nencki). 
Without  bile,  only  61  per  cent,  of  tribenzoicin  were  decomposed  by 
pancreatic  juice;  with  bile,  the  total  amount. 

3.  By  its  alkalinity  it  accomplishes  the  formation  of  soaps. 

4.  Bile  dissolves  fat  in  minute  quantities. 

5.  Bile  dissolves  the  saponified  alkaline  bases  which  are  insoluble 
in  the  juices  of  the  intestines. 

6.  Animal  membranes  moistened  with  bile  are  more  permeable 
to  emulsified  fats  than  membranes  moistened  with  water  (von 
Wisting,  Heidenhain). 


64  THK   f'ORME^D    OR   ORGANIZED    FERMENTS. 

7.  Bile  is  a  stimulant  to  the  intestinal  epithelial  cells,  incites  their 
proper  functioning  and  maintains  it  (Rohmann). 

8.  It  is  claimed  that  albuminous  bodies  and  pepsin,  dissolved  in 
the  chyme,  are  precipitated  as  a  resinous,  sticky  deposit,  which 
adheres  better  to  the  duodenal  wall,  and  effects  a  better  utilization 
of  the  albuminates  thereby. 

9.  An  inhibitory  influence  over  putrefaction  is  ascribed  to  bile 
(Maly  and  Emmerich). 

10.  An  influence  favoring  an  increase  of  the  peristalsis  of  the 
intestine  (Rohmann). 

The  Succus  Entericus. — The  succus  entericus  is  a  secretion  of 
the  crypts  of  Lieberkiihn,  and  was  first  studied  in  man  by  Demant 
after  a  herniotomy.  This  secretion  has  the  color  of  light  Rhine 
wine,  and  is  very  strongly  alkaline,  owing  to  the  presence  of  1.5 
per  cent,  carbonate  of  sodium.  The  principal  constituents  are 
albumins  and  mucin.  It  contains  also  ptyalin  and  an  inverting 
ferment,  but  has  no  effect  on  albumins  and  fats;  its  purpose  seems 
to  be  that  of  a  neutralizer  of  the  acids  originating  from  fermenta- 
tion of  carbohydrates;  its  excess  of  mucin  may  be  instrumental  for 
the  onward  movement  of  the  bowel  contents. 

The  Formed  or  Organized  Ferments  (Bacteria). — Proteids, 
carbohydrates,  and  fats  are  subject  to  decomposition  in  the  intes- 
tines by  bacteria.  Fats  are  not  decomposed  to  any  considerable 
extent  in  the  lower  intestinal  sections  (Nencki  and  Blank),  but  a 
small  fraction  is  split  up  into  glycerin  and  fatty  acids. 

A  greater  interest  attaches  itself  to  the  fermentation  of  carbo- 
hydrates, which  occurs  principally  in  the  upper  small  intestine  and 
leads  to  the  formation  of  acetic,  lactic,  butyric,  and  carbonic  acids, 
alcohols,  and  hydrogen.  It  is  not  known  how  much  of  the  carbo- 
hydrates is  decomposed  in  this  manner. 

The  putrefaction  of  proteids,  caused  by  certain  bacteria  of  the 
lower  bowel,  occurs  chiefly  in  an  alkaline  medium.  The  first  prod- 
ucts of  this  putrefaction  are  the  identical  bodies  which  are  formed 
during  pancreatic  digestion — viz. :  albumoses,  peptone,  amido-acids, 
and  ammonia.  But  then  the  putrefaction  goes  still  further;  tyrosin 
is  formed,  and  from  this,  through  a  series  of  complex  oxyacids,  the 
product  phenol  (carbolic  acid)  is  reached,  which  may  yield  phenyl- 
propionic  and  phenylacetic  acids.  A  second  variety  of  aromatic 
substances,  not  derived  from  tyrosin,  is  represented  by  indol,  skatol, 
and  skatol  carbonic  acid;  finally,  leucin  and  ammonia  salts  of  ca- 


BACTERIA   NOT   ESSENTIAL  TO   DIGESTION.  65 

pronic,  valerianic,  and  butyric  acids.  The  gases  formed  are  car- 
bonic acid  gas,  hydrogen,  hydrogen  sulphid,  and  methyl-mercaptan. 
As  bacteria  can  produce  peptone,  it  might  be  presumed  that  such 
product  may  be  useful  to  the  organism.  This  peptone  is  not  made 
for  philanthropic  purposes — it  is  simply  one  intermediate,  probably 
unavoidable  stage  in  a  long  chain  of  decompositions. 

We  can  not  measure  the  intensity  of  carbohydrate  fermentation, 
but  the  aromatic  end  products  of  proteid  putrefaction  can  be  ap- 
proximately estimated  by  determination  of  the  amounts  of  combined 
and  ethereal  sulphates  occurring  in  the  urine. 

The  number  of  bacteria  increases  from  the  duodenum  downward 
until  they  become  enormously  profuse  in  the  colon.  They  also 
differ  qualitatively.  In  the  small  intestine,  Gessner  found  a  preva- 
lence of  the  bacterium  lactis  aerogenes  and  streptococcus  pyogenes; 
the  colon  bacillus  was  present,  but  insignificant  in  numbers.  In 
the  colon,  however,  the  reverse  was  the  case.  It  was  formerly  an 
accepted  view,  principally  defended  by  Pasteur,  that  the  intestinal 
bacteria  were  absolutely  indispensable  for  digestion,  and,  therefore, 
for  the  nutrition  of  the  individual.  From  this  view  we  have  returned 
to  what  seems  a  more  logical  belief,  based  on  the  observations  of 
Kscherich,  who  held  that  bacteria  contributed  very  little  to  the 
digestion  of  the  infant,  as  they  do  not  affect  casein  and  fats,  but 
only  sugar  of  milk,  turning  it  into  lactic  and  carbonic  acids  and 
hydrogen.* 

Macfadyen,  Nencki,  and  Sieber  arrived  at  a  similar  conclusion  in 
their  now  classical  observations  on  adults  ("Archiv  fiir  exp.  Patho- 
logic," Bd.  XX VIII,  189 1).  One  of  their  objects  of  study  was  a 
female  with  a  fistula  that  opened  the  small  intestine  on  the  external 
abdominal  wall,  just  at  the  end  of  the  ileum.  The  entire  colon 
was  therefore  excluded  from  the  digestive  act.  As  nearly  all  proteid 
putrefaction  occurs  in  the  colon,  this  case  presented  a  chance  to 
study  the  condition  of  absence  of  products  of  albuminous  putre- 
faction and  its  effects. 

It  was  found  that  bacteria  are  not  at  all  essential  to  digestion, 
as  their  patient  was  very  healthy  without  proteid  putrefaction. 
They  declare  that  the  bacterial  fermentation  of  carbohydrates  in 
the  small  bowel  is  detrimental,  rather  than  advantageous ;  inasmuch 

*The  work  of  Nuttal  and  Thierfelder  shows  that  guinea-pigs  can  live  on  absolutely 
sterile  food,  the  excrement  of  the  animals  being  sterile  also  while  they  were  under  the 
control  of  the  experimenters. 


66  HYDROCHLORIC   ACID    NOT   ABSOLUTELY   ANTISEPTIC. 

as  the  bacteria  live  at  the  expense  of  the  ingested  carbohydrates, 
a  corresponding  amount  of  food  is  lost  to  the  organism. 

Our  knowledge  of  the  bacterial  activity  in  the  intestines,  though 
much  enriched  by  valuable  researches  in  the  last  decade,  is,  ac- 
cording to  our  opinion,  in  its  infancy.  So,  also,  our  knowledge  of 
the  pathogenic  significance  of  intestinal  bacteria.  There  is,  un- 
doubtedly, a  kind  of  interaction  and  correlation  between  digestive 
ferments  and  juices  on  the  one  hand,  and  bacteria  on  the  other,  or 
even  between  bacteria  and  bacteria,  or  between  the  products  of 
bacterial  metabolism.  For  instance,  Metschnikoff  has  demonstrated 
that  the  multiphcation  of  the  cholera  vibrio  is  much  advanced  by 
the  presence  of  torulse  and  sarcinse  in  the  intestines. 

It  is  conceivable  that  bacteria  wage  war  upon  one  another,  as  well 
as  upon  the  cells  of  our  tissue,  and  that  we  are  benefited  by  this 
mutual  self-destruction  of  oiu"  parasitic  inhabitants.  It  is  con- 
ceivable, also,  that  they  fall  a  prey  to  the  poisonous  metaboHc 
products  of  their  own  or  other  species  of  bacteria.  Certain  very 
decomposable  food,  as  cheese  that  was  rich  in  germs,  has  been  found 
by  competent  obserA^ers  to  reduce  the  amount  of  indican  and  of  the 
ethereal  sulphates  in  the  urine,  which,  indicates  a  reduced  putrefaction 
(see  A.  Ivockhart  GiUespie,  "Edinburgh  Medical  Journal,"  November, 
1898,  p.  428). 

The  human  stomach  must  not  be  regarded  as  an  organ  that  can 
absolutely  sterilize  all  food.  The  spores,  being  more  resistant  to 
HCl  than  the  fully  developed  bacteria  themselves,  pass  through 
the  stomach  uninjured.  ]\Iiller  assumes  that  at  the  height  of  diges- 
tion only,  when  the  amount  of  HCl  is  greatest,  the  less  resistant 
bacteria  are  killed.  Bunge,  some  years  ago,  announced  that  the 
principal  object  of  the  HCl  was  one  of  steriHzation.  It  is  undeniable, 
from  recent  investigations,  that  the  human  stomach  is  at  no  time 
free  from  germs.  Captain  and  Morau  found  them  at  the  height  of 
digestion.  Abelous  found  them  in  his  own  stomach  when  it  was 
perfectly  empty.  Miller  (University  of  BerHn)  demonstrated  that 
the  mouth  contains  large  quantities  of  microbes;  in  one  unclean 
individual  he  estimated  the  numbers  of  mouth  bacteria  at  1,140,- 
000,000.  Of  twenty-five  different  varieties  occurring  in  the  mouth, 
this  observer  was  able  to  demonstrate  twelve  of  the  same  in  the 
feces.  Nevertheless,  the  mouth  bacteria,  according  to  Lucksdorff, 
constitute  only  three  per  cent.,  while  those  entering  through  the  food 
constitute  ninety-seven  per  cent,  of  the  bacteria  of  the  intestine. 


INTESTINAL   AUTO-INTOXICATION.  67 

There  is  no  autochthonous  vegetation  of  bacteria  in  the  intestine; 
they  are  all  introduced  from  the  mouth,  or  in  the  food,  or  reach 
there  by  way  of  the  circulation.  (By  autochthonous  bacteria  are 
meant  such  as  are  originally  developed  at  the  place  where  they  are 
found.) 

From  observations  made  up  to  the  present  time  it  seems  probable 
that  catarrhal  and  other  inflammatory  diseases  of  the  intestinal 
mucosa  are  not  produced  by  specific,  constantly  recurring  microbes, 
but  that  many  kinds  of  bacteria  are  capable  of  producing  these  dis- 
eases under  conditions  which  are  thus  far  not  perfectly  understood. 

It  appears,  furthermore,  that  the  same  bacterium  may  at  one 
time  be  perfectly  harmless,  or  it  may  cause  a  light,  trivial  affection, 
or  at  other  times  a  very  serious  disturbance.  This  is  the  case  with 
the  bacterium  coli  communis,  which  is  tolerated  without  detriment 
by  the  majority  of  mankind;  but  occasionally  it  is  demonstrated  as 
the  producer  of  colitis,  dysentery,  and  cholera  nostras. 

The  manifold  forms  of  the  catarrhal  inflammations  are  explicable 
by  the  fact  that  the  intestinal  flora  is  also  very  manifold.  These 
same  bacteria  are  factors  in  the  etiology  of  diseases  of  the  peritoneum, 
and  of  all  organs  that  are  in  connection  with  the  intestines.  Even 
remote  organs,  not  in  anatomical  connection  with  the  bowel,  are  not 
safe  from  their  invasion. 

They  are  known  to  gain  entrance  into  the  blood  and  lymphatic 
channels  through  losses  of  substance  in  the  intestinal  mucosa.  The 
experiments  of  Posner  and  Lewin  have  taught  us  that  even  without 
such  p'ortals  of  entry  they  seem  to  be  able  to  pass  through  the  bowel- 
wall  in  masses,  and  threaten  the  organism.  Hans  Hensen  ('  *  Zeitschr. 
f.  Biol.,"  Bd.  XXXV,  p.  no)  has  shown  that  bacteria  can  penetrate 
natural  and  artificial  membranes  that  allow  diffusion.  There  are 
fine  canals,  passable  for  bacteria,  that  can  not  be  demonstrated  by 
the  hemoglobin  test.  Great  harm  can  be  done  to  the  general  organ- 
ism, and  to  special  organs  in  particular,  not  only  from  this  invasion, 
but  also  from  absorption  of  the  soluble  products  of  bacterial  metabol- 
ism and  of  food  decomposition. 

This  condition  of  self-poisoning  from  toxic  substances  in  the 
individual's  own  intestinal  canal  is  spoken  of  as  intestinal  auto- 
intoxication. Not  all  auto-intoxications  are  of  intestinal  origin; 
diabetes  mellitus,  for  instance,  is  an  auto-intoxication  by  grape 
sugar,  which  is  in  this  case  a  product  of  disturbed  metabolism,  and 
does  not  originate  from  the  digestive  canal. 


68      EFFECTS   OF   THE   ACTION   OF   SOME   DIGESTIVE   SECRETIONS. 

The  dangers  which  threaten  the  general  organism  from  the  intes- 
tinal bacteria  have  given  rise  to  many  efforts  to  sterilize  the  digestive 
tract  by  means  of  so-called  antiseptics.  Most  of  the  agents  used 
for  this  purpose — calomel,  salol,  naphthalin,  beta-naphthol,  bismuth, 
creosote,  bismuth  salicylate — are  themselves  toxic,  and  in  doses 
sufhciently  large  to  reduce  the  number  of  bacteria  to  any  considerable 
extent,  are  harmful  to  the  body.  The  putrefaction  of  proteids,  as 
measured  by  the  relation  between  the  amounts  of  the  combined 
and  ethereal  sulphates  in  the  urine,  can  only  be  temporarily  dimin- 
ished by  this  method. 

Intestinal  disinfection  is  therefore  an  unsolved  problem.  Efforts 
in  this  direction  should  still  be  encouraged,  because  we  may  be  able 
thereby  to  attenuate  the  pathogenic  inhabitants  of  our  intestines  and 
render  them  less  virulent.  The  best  disinfectant  of  the  human  in- 
testine is  its  normal  action,  and  the  best  way  to  control  putrefaction 
is  by  the  selection  of  adapted,  appropriate  diet,  by  fresh  air,  moderate 
exercise,  good  sleep,  pure  water,  and  by  the  avoidance  of  overeating 
and  overdrinking  (Hemmeter,  ' '  On  Intestinal '  Putrefaction  and 
Albuminuria,"  "Maryland  Medical  Journal,"  July  24  and  31,  and 
August  7,   1897). 


CHAPTER  VII. 

EFFECTS  OF  THE  ACTION    OF  THE  SEVERAL  DIGESTIVE 

SECRETIONS.— METHODS  FOR  TESTING  THE 

MOTOR  FUNCTIONS  OF  THE  STOMACH. 

When  the  gastric  chyme  enters  the  duodenum,  the  albuminoid  and 
proteid  foods  appear  partly  as  syntonin,  albumoses,  and  peptones, 
and  partly  unchanged.  The  carbohydrates  appear  either  as  erythro- 
dextrin,  achroodextrin,  or  maltoses,  and  partly  unchanged.  The  fats 
are  unchanged ;  rarely  are  they  found  split  up,  so  that  one  can  detect 
traces  of  fatty  acids. 

Water,  according  to  the  interesting  investigations  of  von  Mering, 
is  absorbed  only  in  very  small  quantities  from  the  stomach.  It  ap- 
pears that  fully  ninety  per  cent,  of  all  water  taken  into  the  stomach 
is  passed  into  the  duodenum;  alcohol,  and  whatever  is  in  solution 
in  it,  is  absorbed  readily.     Grape-,  milk-,  and  cane-sugar,  also  mal- 


THE    ACTION    OF    BILE.  69 

tose,  are  absorbed  in  moderate  amounts  when  they  are  in  aqueous 
solution.  When  they  are  in  alcohohc  solution,  larger  amounts  are 
absorbed.  Dextrin  and  peptone  are  also  taken  up  from  the  stomach, 
but  in  smaller  quantities  than  sugar.  The  amount  of  the  substances 
resorbed  increases  with  the  concentration  of  the  solution.  Simul- 
taneously with  this  resorption,  a  more  or  less  active  secretion  of 
water  occurs  into  the  stomach.  This  secretion  increases  or  diminishes 
as  the  quantity  of  substances  resorbed .  or  taken  up  increases  or 
diminishes. 

Secretion  of  water  occurs  even  when  no  HCl  is  demonstrable  in 
the  normal  stomach.  The  chyme,  then,  as  it  enters  the  duodenum, 
still  contains  all  of  its  water,  but  is  minus  some  of  the  peptones, 
dextrins,  sugars,  and  alcohols.  It  is  more  or  less  acid  from  free  HCl. 
When  the  bile  acts  on  this  acid  chyme,  a  resinous,  flocculent  pre- 
cipitate is  deposited  from  it  on  the  walls  of  the  duodenum;  at  the 
same  time  a  finely  granular  cloudiness  occurs.  The  resinous  deposit 
consists  of  bile-acids  and  syntonin  (Hammarsten),  and  the  granu- 
lar opactiy  is  due  also  to  bile-acids  and  small  amounts  of  peptone. 

Excess  of  bile  may  redissolve  these  precipitates  so  that  they  can 
not  at  times  be  found  in  animals  killed  at  the  height  of  digestion. 
The  digestion  by  pepsin  is  checked  by  the  complete  neutralization 
of  HCl  by  pancreatic  juice,  bile,  and  succus  entericus.  If  any  pre- 
cipitation occurs  as  stated,  pepsin  is  also  thrown  down  and  resorbed 
again  or  digested  by  trypsin.  The  bile  does  not  disturb  the  pro- 
teolytic power  of  pancreatic  juice  (Claude  Bernard).  Boas  and  the 
author  have  shown  that  the  clear  duodenal  chyme  w^ill  digest  8 1  per 
cent,  of  serum-albumin  in  three  hours;  at  40°  C.  its  alkalinity  was 
0.8  per  cent.  NajCOs.  It  was  also  shown  that  this  duodenal  chyme 
converted  25  per  cent,  of  starch  into  maltose,  and  that  it  produced 
12. 1  per  cent,  fatty  acids  from  neutral  olive  oil  in  three  hours.  Boas 
obtained  his  mixture  of  bile,  pancreatic  juice,  and  succus  entericus 
from  a  patient  who  had  most  probably  a  duodenal  stenosis  and  who 
vomited  this  chyme  frequently.  In  the  author's  experiments  the 
duodenal  secretions  were  obtained  by  his  method  of  intubation  of 
the  duodenum.  The  contents  of  the  duodenum  are  acid,  even  in 
cases  where  no  HCl  is  secreted  in  the  stomach. 

It  was  found  in  these  experiments  that  the  duodenal  juices,  when 
filtered,  digested  85  per  cent,  to  95  per  cent,  of  Merck's  dried  serum- 
albumin  in  three  hours  at  40°  C.  The  author's  results  with  starch 
conversion  show  that  the  filtered  duodenal  juices  will  digest  42  per 


70  INTERACTION   OF   DUODENAL   SECRETIONS. 

cent,  of  starches,  or  rather  convert  them  into  maltose,  which  is  con- 
siderably in  excess  of  the  figures  obtained  by  Boas.  The  fat-splitting 
effect  observed  by  us  in  this  juice  was  nearer  the  result  of  Boas, 
for  we  found  that  15.3  per  cent,  of  fatty  acids  were  obtained  from 
neutral  olive  oil.  In  a  case  of  biliary  calculi,  we  have  been  able  to 
obtain  the  pancreatic  juice  free  from  bile,  as  the  bile-ducts  must 
have  been  stenosed  either  by  a  small  calculus  or  a  bit  of  thickened 
bile  and  mucus  mixed. 

The  fat-splitting  effect  of  pancreatic  juice  is  improved  by  the 
presence  of  bile,  as  is  also  the  amylolytic  action  of  amylopsin. 

Demonstration. — The  action  of  pancreatic  juice  obtained  from  a 
dog  on  neutral  olive  oil  and  on  a  solution  of  starch  should  be  studied 
both  with  and  without  bile.  Pancreatic  juice  plus  bile  will  split 
up  more  fat  and  convert  more  starch  into  maltose  than  without  bile 
(Martin  and  Williams). 

The  effect  of  trypsin  on  pepsin  is  not  definitely  known,  but  it  is 
probable  that  pepsin,  being  closely  allied  to  proteids,  is  disintegrated 
by  trypsin ;  but  in  an  acid  solution  pepsin  checks  the  action  of  trypsin 
(Kuhne,  Langley,  Ewald,  and  Baginsky).  According  to  Baginsky, 
rennin  is  destroyed  by  a  neutral  solution  at  room  temperature. 
The  ferment  action  of  bacteria  in  the  small  intestine  is  limited  to 
the  carbohydrates.  Discharges  of  food  from  fistulse  of  the  small 
intestine  show  no  fetid  decomposition  of  albuminoids  (Ewald  and 
Nencki).  The  absence  of  proteid  putrefaction  in  the  small  intestine 
is  probably  due  to  the  rapid  downward  movement  of  the  food  mass 
in  this  portion  of  the  bowel  and  to  its  acid  condition. 

Carbohydrate  fermentation  yields  mainly  lactic  acid,  ethyl  alcohol, 
carbon  dioxid,  and  hydrogen.  Macfadyen,  Nencki,  and  Sieber  found 
the  chyme  that  passed  over  into  the  large  intestine  (the  cecum) 
from  the  ileum  to  be  550  gm.,  with  4.9  per  cent,  solid  residue  in  case 
the  chyme  was  of  a  very  thin  consistence;  and  232  gm.,  with  11.23 
per  cent,  solid  residue,  if  the  chyme  was  very  condensed.  Both  of 
these  figures  are  the  amounts  passing  in  twenty-four  hours.  The 
shortest  time  in  which  food  passed  into  the  cecum  after  it  was  swal- 
lowed was  two  hours ;  the  longest  period,  five  and  a  quarter  hours. 

The  reaction  expressed  in  acetic  acid  was  equal  to  one  per  thou- 
sand; the  acidity  is  considered  to  be  due  to  newly  formed  acetic 
acid,  as  the  lactic  acid  and  the  HCl  are  neutrahzed  by  the  succus 
entericus.  This  chyme  contained  one  per  cent,  albumin;  also  pep- 
tone, mucin,  dextrin,  sugar,  lactic  acid,  sarcolactic  acid,  and  traces 


NATURE   OF   CONTENTS   OF   ILEUM   AND   COLON.  7 1 

of  fatty  acids;  it  contained  no  leucin,  tyrosin,  urobilin,  or  ammonia. 
The  characteristic  products  of  albuminoid  decomposition  were 
absent. 

Jaworski's  investigation  on  the  contents  of  the  large  intestine, 
which  were  discharged  from  a  fistula  in  the  ascending  colon,  showed 
that  the  daily  fecal  discharge  of  150  to  200  grs.  was  decidedly  alka- 
line, and  contained  the  products  of  proteid  and  albuminoid  decom- 
positions, viz. :  urobilin,  skatol,  phenol,  oxyacids,  ammonia,  leucin, 
cadaverin,  ethyl  and  butyl  alcohol,  sulphuretted  hydrogen,  and 
methyl-mercaptan. 

In  view  of  the  fact  that  the  putrefaction  of  albuminoids  and  pro- 
teids  occurs  mainly  in  the  colon,  it  is  of  interest  to  know  how  much 
of  this  class  of  food  substances  is  left  for  the  colon,  and  how  much 
is  digested  in  the  small  intestine.  Nencki  found  that  when  the  food 
contained  70.74  gm.  albumin,  which  represent  10.602  gm.  nitrogen, 
the  amount  of  solid  material  discharged  from  a  colon  fistula  in 
twenty-four  hours  was  26.5  gm.,  with  1.61  gm.  nitrogen,  which 
represented  10.06  gm.  albumin.  From  this  it  is  evident  that  14.25 
per  cent.,  or,  in  other  terms,  only  one-seventh  of  the  total  albumin, 
is  left  for  digestion  in  the  colon,  and  that  85.75  P^r  cent,  is  resorbed 
from  the  stomach  and  small  intestine. 

The  intensity  of  putrefaction  in  the  colon  depends  upon  four 
factors:  (i)  The  amount  of  decomposable  albuminoid  materials  in- 
gested; (2)  the  duration  of  their  retention  in  the  colon;  (3)  the  vigor 
and  tonicity  of  the  intestinal  peristalsis;  and  lastly  (4)  the  chemical 
reaction;  for  a  very  strong  acid  reaction,  due  to  free  acids,  inhibits 
putrefaction. 

Bile  assists  in  this  inhibition.  Hirschler  has  demonstrated  that 
carbohydrates  suppress  putrefaction  considerably;  this  is  due  to 
the  lactic,  butyric,  acetic,  and  carbonic  acids  caused  by  their  fer- 
mentation. Albumin  and  peptone  are  absent  from  the  contents  of 
the  rectum  (feces),  but  are  present  in  typhoid  fever  (von  Jaksch). 
Peptone  is  found  in  all  diseases  that  may  produce  pus  in  the  evacua- 
tions— for  instance,  dysentery,  tuberculous  intestinal  ulcers,  per- 
foration, peritonitis,  hepatic  cirrhosis,  and  carcinoma. 

A  very  important  inquiry  is  that  into  the  ultimate  fate  of  the 
digestive  ferments:  Do  they  pass  through  the  entire  intestinal  tract? 
are  they  absorbed  or  are  they  decomposed?  or  do  they  appear  in 
their  active  form  in  the  feces  ?  This  question  is  a  very,  difficult  one 
to  solve,  as  our  only  method  of  detecting  pepsin,  chymosin,  trypsin. 


72  FATE   OF   DIGESTIVE   FERMENTS. 

and  ptyalin  is  by  their  digestive  activity.  In  all  experiments  of  this 
kind  the  feces  must  be  first  sterilized  by  saturated  solutions  of  thymol ; 
before  using  this  it  is  well  to  exclude  the  action  of  peptonizing  bac- 
teria by  filtering  through  a  Pasteur  filter. 

If  we  found  in  the  glycerin  extract  of  the  sterilized  feces  a  sub- 
stance which  would  dissolve  boiled  egg-albumen  in  a  solution  of  0.2 
per  cent.  HCl,  we  should  be  justified  in  concluding  that  it  was  pepsin. 
If  it  did  not  digest  in  HCl,  but  in  a  one  per  cent,  solution  of  sodium 
carbonate,  it  would  probably  be  trypsin. 

For  the  demonstration  of  a  diastatic  ferment  a  dilute  solution  of 
starch  is  brought  into  the  incubator  with  about  five  c.c.  of  filtered, 
steriHzed  feces.  After  a  few  hours  the  HCl  and  soda  solutions  of 
the  boiled  albumin  are  tested  for  peptone  by  the  biuret  reaction, 
and  the  diastatic  test-tube  is  tested  with  a  dilute  solution  of  iodin 
in  iodid  of  potassium.  If  the  starch  is  unchanged,  the  solution  will 
be  changed  to  blue ;  if  not,  the  color  will  be  brown  or  yellow. 

In  this  way  we  have  confirmed  the  fact  that  pepsin  is  absent  from 
the  colon  contents,  but  trypsin  is  at  times  present,  since  the  perfectly 
sterile  extract  of  feces  will  digest  fibrin  and  albumin  in  alkaline 
solution. 

The  digestive  action  of  the  succus  entericus,  which,  according  to 
Griitzner,  has  a  weak  fibrin-dissolving  property,  does  not  extend  to 
the  albumins,  and  therefore  it  will  not  confuse  the  result  stated  above 
as  pertaining  to  pepsin  and  trypsin. 

The  chief  digestive  action  of  succus  entericus  is  on  the  carbohy- 
drates. If  peptone  occurs  in  the  stools,  it  is,  in  the  author's  opinion, 
a  product  either  of  pepsin  or  trypsin  digestion,  not  exclusively  of 
bacterial  origin.  Undoubtedly,  there  are  proteolytic  bacteria — for 
instance,  the  bacillus  subtilis  of  Khrenberg,  the  proteus  vulgaris  of 
Hauser,  the  bacillus  putrificus  coli  of  Bienstock,  and  the  bacillus 
hquefaciens  ilei  of  Macfadyen,  Nencki,  and  Sieber,  all  of  which  exist 
ordinarity  in  the  human  intestine ;  and  their  first  products  of  action 
on  albumins  are  the  same  as  occur  in  normal  pancreatic  digestion, 
viz. :  albumoses,  peptones,  amido-acids,  and  ammonia ;  but  then  the 
action  continues  uninterruptedly,  ending  in  the  formation  of  decom- 
position products  stated  in  a  previous  paragraph.  The  bacterial 
product  of  peptone  is  probably  of  no  use  to  the  organism  in  which  it 
occurs — it  is  a  first  stage  to  proteid  putrefaction,  and  these  proteo- 
lytic parasites  need  peptone  for  their  own  existence. 

The  remote  possibility  that  only  bacteria  could  produce  peptone 


MOTOR   FUNCTIONS    OF    THE    STOMACH.  73 

in  the  colon  (feces)  might  be  excluded  by  the  fact  that  after  steriliza- 
tion of  the  feces  by  a  saturated  solution  of  thymol,  peptone  will,  in 
some  cases,  still  be  produced  when  the  above  tests  are  made.  It  is 
due  most  probably  to  trypsin,  which  is  present  in  the  stools  when 
they  have  traversed  the  intestines  rapidly. 

Starch-inverting  ferments  are  present  in  the  saliva,  pancreatic 
juice,  and  succus  entericus;  hence,  if  such  a  ferment  appears  in  the 
feces,  it  is  impossible  to  decide  upon  its  source. 

Amylopsin  and  steapsin  have  not  been  demonstrated  as  such  in 
normal  feces.  It  is  not  known  whether  pepsin  and  rennin  (chymosin) 
occur  in  normal  feces.  We  have  found  a  proteid-dissolving  ferment 
in  the  stool,  which  acted  in  a  one  per  cent,  solution  of  carbonate 
of  sodium  only,  and  was  studied,  in  a  case  of  complete  atrophy  of 
the  gastric  mucosa,  with  total  absence  of  HCl,  pepsin,  and  chymo- 
sin, and  also  of  the  proenzymes  of  these  ferments.  In  the  wash- 
water,  bits  of  mucosa  were  found  that  proved  the  absolute  destruc- 
tion of  the  glandular  apparatus  of  the  stomach. 

It  is  probable  that  this  ferment  was  trypsin.  There  was  a  mod- 
erate gastrectasia,  but  otherwise  no  anatomical  defect  was  observa- 
ble. The  stools  were  not  diarrheic.  Escherich's  assertion  that  the 
colon  bacteria  do  not  live  upon  the  food  introduced, — as,  accord- 
ing to  his  opinion,  there  is  no  digestible  food  left  there  under  normal 
conditions, — but  that  they  live  upon  the  secretions  of  the  walls  of 
the  colon,  is  certainly  erroneous — if  this  statement  of  his  view  is 
correct  (quoted  from  Mannaberg,  in  Nothnagel's  "  Erkrankungen 
des  Darms,"  p.  38). 

The  conception  of  some  writers  on  this  subject  that  food  materials 
are  completely  used  up  in  the  digestive  tube,  is  not  proved  by  actual 
fact.  Even  meat,  when  eaten  in  a  most  digestible  form,  is  found 
in  visible  traces  undigested  in  the  evacuations.  It  is  therefore  more 
than  probable  that  the  colon  bacteria  live  at  the  expense  of  the 
ingested  proteid  food. 

Having  thus  far  reviewed  the  physiology,  anatomy,  and,  in  part, 
the  pathology  of  food  digestion  in  general,  let  us  now  return  to  the 
special  pathology  of  the  functions  of  the  stomach,  as  a  preparation 
for  a  better  comprehension  of  its  diseased  states. 

Qualitative  and  Quantitative  Methods  for  Testing  the  Motor 
Functions  of  the  Stomach. — The  motor  or  peristaltic  function  is 
the  most  important  one.  A  man  may  be  able  to  live  without  the 
secretory  and  resorptive  functions  of  his  stomach,  as  the  intestinal 


74  DURATION    OF    GASTRIC    DIGESTION. 

digestion  and  secretion  would  suffice  for  amylolysis  and  proteolysis, 
and  he  depends  upon  the  small  intestine  altogether  for  the  digestion 
and  absorption  of  fats;  so  that  even  in  the  total  absence  of  gastric 
resorption  and  the  falling  away  of  secretions  of  HCl,  pepsin,  and 
rennin  ferments,  life  could  be  maintained. 

But  if  the  motor  function  is  interfered  with,  the  food  would  re- 
main in  the  stomach  and  accumulate.  If  a  normal  gastric  juice 
were  even  possible  when  the  peristalsis  is  paralyzed,  the  food  could 
be  only  partly  digested.  Carbohydrates  and  fats  would  not  be 
digested.  When  the  limit  of  distention  was  reached,  the  food  would 
be  ejected  as  in  pyloric  stenosis  and  gastrectasia. 

In  all  cases  of  inhibition  or  loss  of  motor  power,  the  secretory 
power  is  seriously  disturbed,  or  may  cease  absolutely;  so  also  the 
resorptive  power.  (See  chapters  on  Supersecretion  and  Motor  In- 
sufficiency.) Many  cases  of  total  absence  of  gastric  secretions  have 
been  reported  in  patients  whose  body-weight  remained  normal  and 
their  general  health  unimpaired.  The  stomach  has  been  removed 
experimentally  in  dogs,  and  the  animals  continued  to  thrive  without 
it,  if  precautions  were  taken  to  provide  finely  divided  food.* 

There  have  been,  up  to  very  recently,  six  different  methods  pro- 
posed for  determining  the  motor  functions  of  the  human  stomach: 
the  methods  of  I^eube,  Ewald  and  Sievers,  Klemperer,  Fleischer, 
Binhorn,  and  Hemmeter. 

Leube's  method  of  estimating  the  duration  of  gastric  digestion — 
i.  e.,  to  determine  after  a  definite  average  time  of  six  to  seven  hours 
after  a  meal  of  50  gm.  bread,  200  gm.  beefsteak,  and  a  glass  of  water, 
or  two  hours  after  an  Ewald  test-breakfast,  whether  solid  contents 
are  still  to  be  found  in  the  stomach — will  serve  the  practitioner 
with  a  simple  and  ready  method,  which  follows  naturally  in  the  line 
of  drawing  test-meals  from  the  stomach;  it  is,  however,  subject  to 
too  many  physiological  variations  to  permit  of  accurate  deductions. 

Ewald  has  proposed  the  use  of  salol,  which,  according  to  Nencki, 
is  not  decomposed  by  acids  in  the  stomach,  but  is  converted,  by 
the  alkaline  juices  of  the  duodenum,  into  salicylic  acid  and  phenol. 


*  Schlatter,  of  Ziirich  ("  Med.  Record,"  1S97,  Lil,  909),  and  Dr.  Brigham  ("  Journ. 
Amer.  Med.  Asso.,"  Feb.  12,  1898)  have  successfully  removed  the  entire  stomach  from 
human  patients  in  whom  the  digestive  process  continued  practically  normal,  at  least  up 
to  the  date  of  publication.  Much  is  yet  to  be  learnt  from  the  future  of  these  two  cases. 
Even  a  year  of  artificial  life  under  the  constant  care  of  a  physician  does  not  prove  that  the 
stomach  can  be  dispensed  with. 


METHODS   I^OR  TESTING  THE   GASTRIC   PERISTALSIS.  75 

He  and  Sievers  found  that  the  appearance  of  saHcyluric  acid — the 
product  of  the  decomposition  of  the  salol  in  the  urine — would  indi- 
cate that  the  salol  had  actually  passed  out  of  the  stomach. 

Normally,  salicyluric  acid  will  appear  in  the  urine  from  forty  to 
seventy-five  minutes  after  taking  one  gm.  of  salol.  Delay  in  its  ap- 
pearance will  indicate  a  retardation  in  the  passage  of  food  into  the 
intestines. 

Salicyluric  acid  is  recognized  in  the  urine  by  the  violet  color  pro- 
duced on  the  addition  of  neutral  ferric  chlorid  solution.  This  method 
necessitates  frequent  urination  of  the  patient— every  five  minutes, 
at  least;  otherwise  the  result  will  not  be  accurate. 

Brunner,  Riegel,  and  Eichhorst  found  that  the  time  in  which  the 
reaction  occurred  in  the  healthy  individual  varied  from  forty  minutes 
to  two  hours.  This  was  to  be  anticipated,  as  the  period  during 
which  a  test-meal  may  remain  in  the  stomach  may  vary  normally 
between  two  and  three  hours. 

A.  Lockhart  Gillespie  found  that  in  the  dog  salol  was  not  decom- 
posed above  the  mid-ileum,  and  suggested  that  salol  can  pass  un- 
changed through  the  stomach-wall  and  become  altered  in  the  blood, 
its  derivatives  appearing  in  the  urine. 

The  duodenum  was  severed  close  to  the  stomach,  and  the  pyloric 
end  of  the  stomach  pulled  through  the  abdominal  wall.  Although 
it  was  thus  impossible  for  the  drug  to  reach  the  bowel,  the  dog's 
urine  contained  salicyluric  acid,  notwithstanding  the  complete  fail- 
ure of  the  test  for  that  body  in  the  contents  of  the  stomach  ("Edin- 
burgh Med.  Journ.,"  Nov.,  1898). 


CHAPTER  VIII. 

METHODS  FOR  TESTING  THE  GASTRIC  PERISTALSIS.—. 

(Continued.) 

Ewald's  salol  test  is  not  applicable  in  private  practice,  because 
of  the  frequent  micturition  that  is  necessary.  It  is  impossible  to 
examine  females  by  this  method  for  the  same  reason;  and,  also, 
because  the  excretion  of  salicyluric  acid  depends  upon  -  the  chang- 
ing energy  of  the  heart's  action,  intra-arterial  pressure,  the  amount 


76  METHODS   FOR   TESTING   THE    GASTRIC    PERISTALSIS. 

of  water  in  the  blood,  and  the  changeable  function  of  the  kidneys 
themselves, 

Huber  improved  this  method  somewhat  by  ascertaining  that  sali- 
cyluric acid  disappears  from  the  urine  in  twenty-four  hours,  after 
the  administration  of  salol  to  healthy  persons ;  but  in  patients  with 
impaired  gastric  peristalsis,  the  reaction  continues  to  be  distinct 
much  longer — sometimes  for  forty-eight  hours.  According  to 
Fleischer  and  Hecker,  the  duration  of  excretion  of  potassium  iodid 
in  the  urine  of  healthy  individuals  varies  from  twenty-nine  to  fifty- 
five  hours;  of  sodium  salicylate,  from  twenty-one  to  twenty-nine 
hours;  and  in  cardiac  and  nephritic  patients  this  may  vary  from 
eighty  to  ninety-six  hours.  It  is  evident  that  methods  of  so  vari- 
able a  character  are  not  satisfactory  for  exact  research;  nor  even, 
on  account  of  the  great  loss  of  time,  of  much  value  for  comparative 
tests. 

Klemperer's  method  consists  in  the  introduction  of  loo  gm.  of 
neutral  olive  oil  into  the  perfectly  clean  stomach,  after  lavage, 
through  a  stomach-tube.  Oil  or  fatty  acids,  which  are  formed  in 
traces,  are  not  absorbed  from  the  stomach.  After  two  hours,  all 
oil  yet  remaining  is  washed  out  by  repeated  lavage,  dissolved  in 
ether,  and  weighed  after  removal  of  the  ether  by  distillation.  In 
the  normal  subject  Klemperer  could  find  but  20  to  30  gm.  of  oil; 
the  remaining  70  to  80  gm.  had  passed  into  the  intestine.  If  larger 
amounts  are  found, — for  instance,  50  to  60  gm.,  or  more, — they  are, 
according  to  Klemperer,  an  evidence  of  motor  insufficiency.  This 
method  requires  much  time  and  skilled  chemical  analysis,  and  is 
also  open  to  the  same  objection  as  that  of  Leube. 

Fleischer  ("Spez.  Path.  u.  Therap.  d.  Magen-  u.  Darmkrankh.," 
p.  791)  has  proposed  a  method  to  determine  the  gastric  peristalsis 
by  giving  o.i  gm.  iodoform  in  a  gelatin  capsule  during  meals;  this 
compound  does  not  decompose  in  acid  media,  but  does  break  down 
in  the  juices  of  the  duodenum,  which  are  less  acid  than  those  of  the 
stomach,  and  one  of  its  resultants  is  potassium  iodid,  which  can 
be  tested  in  saliva  by  starch  paper,  which,  when  dipped  into  the 
sahva,  colors  blue  on  being  touched  with  a  drop  of  fuming  nitric 
acid.  Naturally,  the  potassium  iodid  can  also  be  detected  in  the 
urine;  but  the  fact  which  gives  this  method  the  preference  over 
Ewald's  salol  test  is  that  KI  can  be  detected  in  the  saliva. 

This  method  gives  var^'ing  results,  as  we  have  discovered.  In 
twenty-three  apparently  normal  cases  in  which  we  have  tried  it,  the 


PLATE   III. 


Author's  Method  of  Recording  Gastric  Peristalsis. 

Patient  with  intragastric  bag  within  stomach  and  pneumograph  in  place,  both  connected 

with  the  kymograph. 


PLATE   IV. 


Author's  Method  for  Determining  Location  and  Capacity  of  the  Stomach. 

The  apparatus,  not  including  kymograph.  G.  Intragastric  bag  distended.  F.  The 
esophageal  tube  attached  to  it.  H.  Intragastric  bag  collapsed  in  the  shape  in  which  it 
is  introduced.  A.  Graduated  pressure  bottle  elevated,  filled  with  water.  B.  Stop- 
cock. D.  Lower  graduated  bottle,  empty  at  first.  1  he  bag  is  distended  after  it  is 
swallowed  by  connecting  it  at  E  wiih  D;  the  stop-cock,  B,  is  turned  on,  and  the  water 
then  runs  from  A  to  D,  displacing  the  air  in  D  and  forcing  it  into  the  bag.  Both 
bottles  being  graduated,  the  amount  of  air  in  G  is  always  known,  and  can  be 
utilized  as  an  indication  of  the  gastric  capac'ty. 


IODOFORM   TEST   FOR    GASTRIC    MOTILITY.  77 

reaction  coloring  the  starch  paper  first  occurred  just  one  hour  after 
the  meal  in  twelve  cases;  in  six  cases  it  occurred  first  in  one  hour 
and  twenty  to  twenty-two  minutes;  in  two  cases,  in  one  hour  and 
forty-one  minutes;  and  in  one  case,  in  two  hours.  In  two  cases  it 
took  two  hours  and  a  half  to  demonstrate  KI  in  the  mouth,  after 
giving  0.1  gm.  iodoform. 

The  time  of  the  appearance  of  the  first  red  and  the  subsequent 
blue  coloring  of  the  starch  paper  was  carefully  noted.  Fleischer 
states  that  after  a  test-breakfast  the  reaction  in  the  saliva  should 
occur  in  from  fifty-five  to  one  hundred  and  five  minutes,  which  is 
still  a  considerable  margin  for  variations — too  great  for  practical 
purposes. 

Nevertheless,  the  method  is  interesting,  and,  with  exactly  known 
meals,  might  be  available  for  hospital  work. 

In  Leube's,  Ewald's  and  Sievers',  Klemperer's,  and  Fleischer's 
methods,  it  will  be  observed  that  the  gastric  motility  was  determined 
by  something  that  was  administered  (salol,  iodoform,  and  food)  or 
poured  into  the  stomach  (oil),  and  by  the  absorption  of  the  product 
of  breaking  down  in  the  supposedly  alkaline  duodenum,  and  its 
subsequent  appearance  in  the  secretions  and  excretions  (potassium 
iodid  in  the  saliva  and  salicyluric  acid  in  the  urine) — an  expression 
in  terms  of  time  being  arrived  at,  to  denote  the  intensity  of  the 
gastric  peristalsis. 

In  two  methods  the  expression  is  derived  from  the  quantity  of 
oil  or  food  retained  in  the  stomach  after  two  hours,  but  here  also 
the  result  depended  upon  the  passage  of  something  into  the  duo- 
denum. In  all  of  these  methods,  therefore,  the  fundamental  idea 
is  the  rate  of  expulsion  of  gastric  contents  into  the  duodenum,  as  if 
that  were  the  only  object  of  the  motor  functions  of  the  stomach. 

It  is  probable  that  this,  which  is  only  a  part  of  the  purpose  of 
the  gastric  peristalsis,  was  so  much  dwelt  upon  because  it  offered 
the  most  expedient  means  for  experimenting,  and  a  greater  possi- 
bility of  solution  of  the  problem.  However,  a  second  and  most 
important  purpose  of  the  gastric  peristalsis,  and  one  concerning 
which  none  of  the  methods  referred  to  thus  far  can  instruct  us,  is 
the  moving  about  of  the  ingesta  within  the  stomach — (i)  so  that  they 
may  be.  made  into  a  more  homogeneous  mass;  (2)  that  they  may 
be  brought  into  thorough  contact  with  the  gastric  juice;  and  (3)  to 
stimulate  the  secretion  of  this  juice  by  the  mechanical  stimulation 
of  the  walls  of  the  organ. 


78  METHODS   FOR   TESTING   THE    GASTRIC    PERISTALSIS. 

The  secretion  of  the  gastric  glands  is  not  onh^  stimulated  by  the 
mechanical  irritation  of  the  stomach-walls  during  peristalsis,  but  by 
the  contraction  of  a  liberal  supply  of  muscular  fibers,  which  arise 
from  the  muscularis  mucosae,  and  are  spun  around  the  bases  of  the 
gland  tubules  (see  frontispiece  Hthograph  of  normal  gastric  mucosa) ; 
the  glands  are  no  doubt  themselves  contracted  and  their  contents 
expelled. 

In  some  of  the  batrachians  this  contraction  of  the  gastric  gland 
tubules  by  electric  stimulation  is  visible  under  the  microscope. 

Dr.  Max  Einhorn  has  described,  in  the  ' '  New  York  Medical  Jour- 
nal," September  15,  1894,  an  instrument  which  records  the  gastric 
movements  by  dots  on  a  narrow  piece  of  paper. 

This  apparatus  consists  of  a  ball  about  f  of  an  inch  (14  mm.) 
in  diameter,  which  is  made  up  of  two  hollow  metallic  hemispheres 
screwed  together.  AVithin  this  is  contained  a  second  smaller  ball, 
which  is  attached  to  the  outer  sphere  by  a  non-conductor  so  that  it 
is  insulated  from  it. 

The  central  smaller  ball  bristles  with  small  metallic  spikes  which 
radiate  in  all  directions  from  the  center  to  the  inside  of  the  two 
hemispheres,  but  not  touching  them! 

A  tiny  platinum  sphere  completes  the  interior  of  this  apparatus; 
it  lies  within  the  larger  round  capsule  and  moves  about,  knocking 
at  the  spikes.  When  it  does  so,  it  completes  an  electric  circuit 
between  the  outer  hemispheres  and  the  spikes  of  the  central  ball — 
for  two  insulated  wires,  one  connected  with  the  hollow  ball,  the 
other  with  the  spiked  ball,  run  up  in  a  very  fine,  thin,  rubber  tube 
and  are  connected  with  the  two  poles  of  an  electric  battery.  On 
connecting  the  ball  with  another  part  of  the  apparatus,  the  "ticker" 
(very  much  like  the  instrument  used  at  the  stock  exchanges  for 
reporting  the  variations  in  stock  by  telegraph),  each  motion  of  it 
will  be  recorded  by  lines  or  dots  on  the  paper.  The  ball  is  swallowed 
and  brought  into  the  stomach  by  the  aid  of  a  draft  of  water.  It 
must  be  borne  in  mind  that  the  paper  records  the  motions  of  the  ball 
only;  this  does  not  mean  that  it  records  every  motion  of  the  gastric 
peristalsis. 

In  animals  upon  which  we  experimented  at  the  biological  labora- 
tory of  the  Johns  Hopkins  University,  a  rubber  stomach-shaped 
bag  was  fitted  exactly  to  the  interior  of  the  animal's  stomach  and 
connected  with  a  manometer  on  the  Ludwig  kymographion.  Records 
were  taken  with  the  animal's  abdomen  intact  and  compared  with 


METHODS    FOR   TESTING   THE    GASTRIC    PERISTALSIS.  79 

those  taken  with  the  abdomen  opened,  so  that  the  gastric  peristalsis 
could  be  viewed  by  the  experimenter. 

The  physiological  peristalsis  is  essentially  the  same  whether  the 
animal's  stomach  is  normally  contained  within  the  abdomen  or 
exposed  to  view,  provided  in  the  latter  case  it  is  kept  warm. 

In  our  experiments  the  animals  were  placed  in  a  large  metal 
case  with  a  glass  top;  underneath  the  animal  holder  about  two 
inches  of  water  was  contained  in  the  bottom  of  the  case,  which  was 
kept  at  the  desired  temperature  by  a  number  of  Bunsen  burners 
beneath  the  case.  Thermometers  were  suspended  from  different 
parts  of  the  case  to  register  the  temperature,  for  it  is  most  essential 
that  after  an  animal's  abdomen  has  been  opened  it  should  be  kept 
at  a  constant  temperature  by  moist  steam;  this  also  insures  the 
viscera  against  becoming  dry. 

In  a  similar  manner  Ludwig  and  H.  Newell  Martin  studied  the 
physiology  of  the  mammalian  heart;  Schatz  conducted  his  funda- 
mental investigations  on  the  contractions  of  the  uterus ;  Engelmann 
carried  on  his  pioneer  work  on  the  contraction  of  the  involuntary 
muscle-fibers  of  the  ureter.  Phliiger  and  Heidenhain  have  done 
similar  accurate  work  on  excised  organs,  and  the  results  have  been 
repeatedly  confirmed  by  other  competent  investigators. 

These  epoch-making  experimentations  are  mentioned  to  em- 
phasize the  fact  that  experiments  conducted  on  organs  isolated 
either  entirely  (Martin,  Ludwig,  Engelmann)  or  partially  (Schatz, 
Phliiger)  are  capable  of  giving  perfectly  physiological  contractions 
or  peristalses  which  differ  nowise  from  the  perfectly  normal  ones. 

It  is  frequently  urged  that  these  experiments,  on  account  of  the 
operations  and  the  anesthesia  necessary,  do  not  present  perfectly 
physiological  conditions,  and  that  therefore  the  deductions  made 
therefrom  are  not  logical,  nor  represent  the  true  state  of  normal 
functioning. 

It  is  undeniable  that  we  never  get  at  the  absolutely  exact  normal 
functioning  of  an  organ — the  stomach,  for  instance — during  an 
experiment,  as  ether  and  chloroform  have  an  inhibiting  effect  on 
gastric  peristalsis.  But  we  are  enabled  to  produce  unconsciousness 
of  the  animal  after  a  brief  ether  narcosis  by  brain  compression,  after 
which  the  ether  is  no  longer  necessary,  and  then  the  gastric  peristalsis 
continues  perfectly  normal.  The  stomach  of  the  rabbit  will  show 
normal  peristalsis  after  complete  excision  and  suspension  on  a  hook 
or  clamp  in  a  warm,  moist  chamber. 


So  METHODS    FOR   TESTING   THE   GASTRIC    PERISTALSIS. 

What  brought  us  to  the  idea  of  using  an  intragastric  thin  rubber 
bag  of  the  shape  of  the  stomach  to  record  the  peristalsis,  after  many 
attempts  with  a  small  spherical  bag  that  did  not  exactly  fill  out  the 
entire  lumen  of  the  stomach,  was  the  repeated  observation  that  the 
small,  round  bag,  such  as  Professor  Moritz,  of  Munich,  used,  did 
not  record  every  peristaltic  movement  that  was  visible  to  the  eye 
when  the  abdomen  was  opened. 

We  frequently  noticed  peristaltic  constrictions  of  the  antrum 
pyloricum  when  the  rubber  bag,  of  about  12  cm.  in  diameter,  was 
at  the  cardia  or  fundus,  and  recorded  no  movement  but  that  due  to 
the  pressure  caused  by  the  descent  of  the  diaphragm.  We  con- 
cluded, after  three  months'  experimentation,  that  a  small  intra- 
gastric apparatus  could  not  possibly  record  every  peristaltic  move- 
ment. 

Sometimes  one  could  witness  very  strong  tonic  contractions  of 
seemingly  every  muscle-fiber  of  the  stomach, — it  gave  that  impres- 
sion,— by  which  the  whole  organ  contracted  from  all  sides  by  shorten- 
ing of  every  circular,  oblique,  and  longitudinal  fiber,  and  at  the 
same  time  the  bag  gave  no  record  of  movement,  although  when 
it  was  lying  in  the  fundus  it  was  clearly  being  lifted  up, — it  would 
not  record  until  it  was  compressed  by  food  or  the  opposite  gastric 
wall. 

For  these  reasons  a  bag  was  devised  which  had  the  exact  shape  of 
the  stomach,  but  could  readily  be  swallowed,  and  when  distended 
within  the  organ,  exactly  adapted  itself  to  its  interior,  filling  every 
nook  and  corner  in  it.  If  a  little  food  was  needed  in  the  organ,  we 
simply  did  not  blow  the  bag  up  so  far  as  to  fill  it  out  completely. 

Our  apparatus,  as  has  been  demonstrated  many  times  on  a  large 
variety  of  cases  in  the  clinical  amphitheater  of  the  University  of 
Maryland,  and  in  the  biological  laboratory  of  the  Johns  Hopkins 
University,  is  adjusted  with  great  ease.  By  a  pneumograph  the 
respiration  is  recorded  separately,  and  thus  one  is  enabled  to  differen- 
tiate the  active  from  the  passive  movements. 

A  separate  seconds-pen  gives  on  the  same  paper  a  record  in  time, 
so  that  the  experimenter  can  tell  at  a  glance  the  duration,  beginning, 
and  end  of  the  peristalsis.  While  it  is  a  most  satisfactory  apparatus 
for  recording  the  motor  function,  it  offers  a  reliable  means  of  ascer- 
taining the  size  and  exact  capacity,  and  finally  the  intragastric 
pressure.  No  apparatus  hitherto  devised  combines  these  facilities 
in  so  simple  a  bit  of  mechanism;  for,  taking  away  the  kymograph, 


FEC 


no, 

Tjsis. 
pare 
es  n| 
il  IVcj 


Curve  of  contraction  of  stomach  of  terrapin,  in  which  slow  stinmhitions — i.  e.,  twenty  per  second— are  more  effective  than  rapid  stimulation.     The  number  of  slit 
lations  can  be  so  increased  per  second  that  the  muscle  will  not  contract  at  all. 


EFFECT  OF   FARADAIC  STIMULATION 


^./-V^'V.^'^VA.J-ir/'S'^^W^ 


The  slowing  of  the  cardiac  impulse,  as  shown  in  the  gastric  record,  is  not  a  genuine  cardiac  inhibition,  but  only  an 
apparent  one,  due  to  the  fact  that  the  stomach  draws  away  from  the  diaphragm  and  aorta  during  violent  contractions,  and 
does  not  receive  every  impulse ;  the  radial  pulse  during  this  period  was  undisturbed  and  regular.  Distance  of  secondary 
coil  from  primary  coil,  four  cm.  on  the  sliding  apparatus. 


Hemmeter's  triple  intragastric  bag.     Kymographic  record  of  pyloric  (No.jl), 
niddle  portion  (No.  2),  and  cardiac  end  of  stomach  (No.  3)  in  successive  peristajsis.      ^ 


KYMOGRAPHIC    TRACINGS    OF    GASTRIC    PERISTALSIS    OBTAINED    WITH    THE    AUTHOR'S    GASTROGRAPH. 


author's  method  for  recording  gastric  peristalsis.      8 1 

which  should  be  in  every  medical  school,  its  important  parts  are 
simply  the  intragastric  bag  and  a  manometer. 

In  practice,  a  manometer  connected  with  the  intragastric  bag  will 
answer;  with  watch  in  hand  the  experimenter  is  able  to  count  the 
peristaltic  movements  as  they  are  conveyed  to  the  column  of  water. 
Kinhorn,  in  his  new  book,  "Diseases  of  the  Stomach,"  page  96, 
has  gathered  the  impression  that  the  apparatus  is  of  difficult  adjust- 
ment, because  in  our  first  report  {loc.  cit.)  we  stated  that  only  such 
patients  are  taken  as  have  become  accustomed  to  the  stomach- 
tube,  as  the  nausea  and  vomiting  first  attending  the  initial  intro- 
duction of  the  tube  make  an  exact  record  impossible  (we  lay  great 
stress  here  on  the  word  exact).  No  intragastric  instrument,  not 
even  Binhorn's  electrode,  can  be  introduced  the  first  time  without 
some  nausea.  While  this  may  not  lead  to  emesis,  it  nevertheless 
has  a  great  influence  on  the  number  of  gastric  movements,  as  most 
cases  we  have  tried  generally  show  more  contractions  in  the  first 
experiment  than  in  any  other.  If  the  record  is  to  be  exact,  and 
free  from  objections  that  may  be  urged  on  account  of  the  influence 
of  nervousness,  nausea,  suggestion,  etc.,  a  certain  adaptation  and 
experience  of  the  patient  is  indispensable,  no  matter  what  instru- 
ment is  used.  Probably  none  of  these  apparatuses  will  be  regularly 
used  in  practice ;  they  are  implements  for  the  trained  specialists,  who 
know  how  to  apply  them  and  how  to  interpret  their  results.  Never- 
theless, our  intragastric  bags  are  used  regularly  at  the  University 
of  Maryland  Hospital,  and  exact  results  obtained  thereby,  even  at 
the  first  attempt. 

Our  objections  to  the  Kinhorn  gastrograph  are:  (i)  That  no  dif- 
ferentiation between  the  active  and  the  passive  movements  produced 
by  the  diaphragm  is  possible  thereby;  (2)  that  there  is  no  coincident 
record  of  time  in  seconds  on  the  paper;  (3)  that  the  tonicity  or  in- 
tensity of  a  contraction  can  not  be  adequately  determined ;  (4)  that 
the  slow  but  very  extensive  general  tonic  contractions — a  narrowing 
down,  as  it  were,  of  the  entire  stomach  to  one  point  in  the  center — 
will  probably  be  recorded  by  a  single  dot,  such  as  would  be  made  by 
an  inspiration  also.  At  the  same  time,  when  we  reflect  that  a  bag 
12  cm.  in  diameter  may  miss  some  of  the  contractions  and  fail  to 
record  them,  it  is  difficult  to  imagine  that  the  gastrograph  should 
record  them  all,  being  not  even  an  inch  in  diameter. 

Nevertheless,  Einhorn's  apparatus  marks  an  epoch  in  the  history 
of  the  study  of  stomach  motions  and  their  physiology.     It  is  the 


82  METHODS   FOR   TESTING   GASTRIC    PERISTAI.SIS. 

first  attempt,  and  largely  a  successful  one,  to  obtain  their  record  by- 
mechanical  means. 

Passive  motions  caused  by  the  pulsations  of  the  aorta  and  the 
impulse  of  the  heart  ventricles  against  that  part  of  the  saccus  csecus 
cardiae  which  touches  the  arch  of  the  diaphragm,  and  also  the  res- 
piratory passive  motions  due  mostly  to  the  muscles  of  respiration, 
are,  to  a  small  extent,  participants  in  the  causes  of  gastric  move- 
ments; but  they  can  not  of  themselves  produce  evacuations  of  the 
contents,  as  we  had  occasion  to  observe  in  the  clinic  on  a  hysterical 
girl,  who  had  no  active  stomach  movements,  no  genuine  peristalsis 
at  all,  all  of  her  gastric  movements  being  due  to  respiration  and 
circulation. 

This  girl  showed  a  normal  state  of  the  secretions  after  an  Kwald 
test-meal,  but  at  the  same  time  there  was  stagnation  and  retention 
of  food.  It  is,  therefore,  most  essential  to  be  able  to  distinguish 
between  active  and  passive  movements,  for  a  person  may  have  a 
great  many  movements  of  the  stomach  and  yet  have  no  genuine 
peristalsis  at  all. 

It  is  necessary  to  distinguish  between  methods  for  physiological 
study  of  gastric  peristalsis  and  methods  for  diagnostic  or  clinical 
work.  Our  method  is  available  mainly  for  the  physiological  and 
clinical  laboratories,  though  it  will  give  valuable  information  even 
without  the  kymograph. 


CHAPTER  IX. 

HEMMETER'S  METHOD  FOR  TESTING  THE  GASTRIC 
PERISTALSIS. 

Theories  Concerning  the  Movements  of  the  Ingesta. 

One  of  the  intragastric  stomach-shaped  rubber  bags  which  are 
used  in  our  clinic  consists  of  three  separate  compartments:  the 
first  filling  out  the  pylorus,  the  second  distending  the  middle  portion 
of  the  stomach,  the  third  occupying  a  small  part  of  the  fundus  and 
the  saccus  caecus  cardiae.  (See  "N.  Y.  Med.  Jour.,"  June  22,  1895, 
p.  772,  and  the  accompanying  illustration.)  Each  one  of  these 
compartments  records  on  the  kymograph  by  a  separate  tambour. 


THEORIES    CONCERNING   THE   MOVEMENTS    OE    THE    INGESTA.      83 

In  the  report  referred  to  we  made  the  assertion,  from  the  results 
obtained  with  this  bag,  that  in  the  human  being  most,  if  not  all,  of 
the  peristaltic  waves  are  executed  by  and  start  at  the  pyloric  end. 
This  statement  was  made  before  Moritz's  investigations  were  pub- 
lished in  the  "Zeitschrift  fiir  Biologic,"  proving  that  the  cardiac  end 
and  the  fundus  of  the  stomach  could  not  contract,  even  when  stimu- 
lated by  powerful  faradic  currents  on  both  the  mucous  and  perito- 
neal surfaces. 

One  week  before  our  results  were  published  in  the  "New  York 
Medical  Journal,"  Dr.  S.  J.  Meltzer,  of  New  York,  pubhshed  his  re- 
sults with  direct  and  indirect  faradization  of  the  digestive  canal, 
which  demonstrated  quite  conclusively  that  the  mucous  membrane 
of  the  digestive  canal  ofifers  a  considerable  resistance  to  the  penetra- 
tion of  the  faradic  current  to  the  muscular  coat,  the  greatest  resist- 
ance being  found  in  the  mucous  membrane  of  the  stomach.  Percu- 
taneous and  direct  faradization  of  the  stomach  or  intestines  can  not 
produce  any  contraction  in  these  parts. 

Meltzer  stated  explicitly  the  kind  of  instruments  used, — the  slid- 
ing inductorium  (Schlittenapparat)  of  DuBois  Reymond,  a  Grove's 
cell  prepared  anew  for  each  experiment, — and  also  the  distance,  in 
every  case,  of  the  primary  from  the  secondary  coil.  His  device  of 
including  the  sciatic  nerve  of  an  animal  (nerve-muscle  preparation 
of  hind  leg  of  frog,  most  likely)  in  the  circuit  is  practical,  and  has  for 
a  long  time  been  used  in  our  laboratory. 

The^e  is,  however,  a  very  important  matter  which  physiologists 
must  insist  on  knowing,  and  which  Meltzer  does  not  state,  perhaps 
because  it  was  not  very  readily  ascertained ;  and  that  is,  the  number 
of  stimulations  to  the  second  used  by  him.  Involuntary  muscle- 
fibers  are  much  slower  to  contract  than  voluntary  muscles,  and  in 
electrical  stimulation  experiments  they  contract  much  more  readily 
when  the  number  of  stimulations  does  not  exceed  240  a  minute.  The 
best  contractions  are  obtained  at  a  much  lower  rate  of  stimulation. 

The  vibrator  on  the  DuBois  Reymond  inductorium  was  found, 
after  months  of  experimentation,  to  send  too  many  stimulations 
into  the  gastric  muscle  per  second.  Later  on,  when  we  used  the 
Kronecker  interrupter,  in  connection  with  a  Jacquet  chronograph, 
and  no  more  than  100  stimulations  per  minute,  it  was  found  that  the 
preantral  sphincter  could  be  made  to  contract  with  the  distance  of 
primary  from  the  secondary  coil  =  o,  and  both  electrodes  on  the 
mucosa. 


84  METHODS    FOR   TESTING   GASTRIC    PERISTALSIS. 

To  get  this  result,  it  is  best  to  starve  the  animal  for  twelve  hours, 
as  for  some  reason  yet  unknown,  the  contractions  are  more  unlikely 
to  occur  the  sooner  the  experiment  is  made  after  the  ingestion  of 
food.  Still,  it  must  be  emphasized  that  the  mucosa  of  the  stomach 
is  practically  a  non-conductor.  We  have  had  occasion  to  try  this 
in  the  physiologiacl  laboratory,  with  a  bit  of  healthy  human  stomach- 


FiG.  7.— ^Intragastric  Tissue  Rubber  Bag,  with  three  disthict  parts  and  three  separate  outlets 
for  recording  the  origin  and  direction  of  gastric  peristalsis.  Outside  of  the  mouth  the  triple 
tube  separates  into  its  three  component  tubes,  each  being  connected  with  a  separate  tamboui 
and  glass  ink  pen,  writing  the  gastric  contractions  and  relaxations  on  the  kymograph.  Part 
No.  I  records  the  contraction  of  the  pylorus  ;  part  No.  2,  the  middle  of  the  stomach  ;  and  part 
No.  3,  of  the  cardiac  end.     (See  double  |)late  for  tracings  of  this  apparatus.) 


mucosa  which  one  of  our  students  tore  off  from  the  wall  of  his  stomach 
during  experimental  lavage;  the  piece  was  fifteen  mm.  long,  five  to 
six  mm.  broad,  and  two  to  four  mm.  thick.  The  gentleman  in  ques- 
tion, after  trying  to  wash  his  stomach  out,  and  not  succeeding  to  his 
satisfaction,  connected  the  end  of  the  tube  with  a  suction  apparatus 
(aspirator). 


THE    MUCOSA    A    NON-CONDUCTOR.  85 

This  was  followed  by  copious  hematemesis,  for  which  we  were 
hastily  summoned.  In  the  stomach-tube,  partly  projecting  from 
the  lower  opening,  was  a  bit  of  fleshy  substance,  which,  on  micro- 
scopic examination,  proved  to  be  gastric  mucosa.  After  the  hem- 
orrhage ceased,  the  young  man  was  treated  for  one  week  as  if  he  had 
gastric  ulcer.  He  did  not  experience  any  pain  during  the  accident, 
nor  thereafter;  the  only  thing  that  frightened  him  was  the  blood. 
He  made  a  good  recovery.  This  bit  of  mucosa  was  placed  in  a  con- 
tinuous circuit  generated  by  a  battery  of  three  freshly  prepared 
Grove's  cells,  with  a  milliamperemeter,  soon  after  it  was  found;  the 
meter  indicated  but  three  milliamperes.  As  it  was  impossible  to 
get  this  fresh  piece  of  mucosa  into  the  circuit  perfectly  dry,  it  is 
probable  that  the  indication  of  three  milliamperes  was  brought  about 
through  the  conducting  agency  of  the  moisture  on  the  outside  of 
the  tissue. 

In  the  biological  laboratory  of  the  Johns  Hopkins  University  we 
have  frequently  had  persons'  stomachs  connected  with  the  kymo- 
graph, and  an  intragastric  rubber  bag  blown  up  to  fill  out  their 
stomachs  exactly.  Through  the  intragastric  bag  ran  two  insulated 
wires,  one  ending  in  a  small  brass  knob  near  the  pylorus,  the  other 
coming  out  against  the  mucosa  near  the  cardia  in  a  similar  knob. 

Every  active  and  passive  motion  was  recorded  by  a  manometer 
pen  ("N.  Y.  Med.  Jour.,"  June  22,  1895,  p.  771).  But  the  strongest 
faradic  currents  (distance  of  primary  from  secondary  coil  =  o) 
could  produce  no  contractions  of  the  stomach. 

Dr.  George  P.  Dreyer  and  myself  held  one  of  the  poles  in  the  right 
hand — the  plus,  for  instance — while  the  negative  was  in  the  stomach ; 
with  the  left  hand  we  touched  the  back  of  the  person's  neck,  thus 
completing  the  circuit.  The  current  was  so  strong  that  it  became 
intolerable  to  us.  Although  this  current  made  its  circuit  through 
the  patient's  stomach,  it  caused  no  contraction,  as  was  evidenced 
by  the  manometer  in  connection  with  the  intragastric  bag. 

Frequently  we  could  observe  contractions  of  any  skeletal  muscle 
upon  which  the  outer  electrode  was  placed, — for  instance,  the  gas- 
trocnemius,— and  still  the  stomach  did  not  contract.  This  proves 
that  in  some  conditions  the  gastric  mucosa  may  transmit  a  current, 
yet  the  muscular  layer  give  no  evidence  of  contractions.  We  do 
not  wish  to  imply  that  it  is  absolutely  impossible  to  contract  the 
human  stomach  by  electrical  stimulation ;  but  the  current  required  to 
effect  this  must  be  so  strong  that  the  experiment  becomes  hazardous. 


86  METHODS   FOR  TESTING   GASTRIC   PERISTALSIS. 

Einhorn  ("Diseases  of  the  Stomach,"  pages  78-83)  and  Paul 
Cohnheim  ("Archiv  f.  Verdauungskrankheiten, "  Bd.  i,  S.  274) 
have  described  tiny  bits  of  mucosa  which  are  found  in  the  wash- water 
and  vomit  of  many  gastric  suiferers.  We  can  confirm  this  observa- 
tion, and  add  that  we  have  found  these  pieces  of  gastric  mucosa  on 
washing  out  the  stomachs  of  perfectly  healthy  persons. 

It  has  occurred  to  us  that  in  rare  instances  in  which  a  good  contrac- 
tion of  the  stomach  was  obtained,  it  was  due  to  the  fact  that  the  cur- 
rent found  its  way  to  the  muscular  layer,  through  spots  from  which 
the  glandular  layer  had  been  cast  off.  It  must  not  be  omitted  that 
all  stomachs  experimented  upon  by  our  method  in  this  series  were 
washed  out  prior  to  the  experiment  to  insure  absence  of  current- 
interrupting  food-particles  in  the  organ. 

Moritz  experimented  with  an  apparatus  very  similar  to  ours, 
except  that  his  rubbdr  intragastric  bag  was  round,  not  stomach- 
shaped.  It  did  not,  therefore,  exactly  and  completely  fill  out  the 
organ,  nor  did  he  use  the  graduated  pressure  bottles,  by  which  it 
is  possible  to  determine  exactly  how  much  air  is  blown  into  the  bag. 
Instead  of  a  pneumograph,  he  used  a  perforated  cork  in  one  nostril 
of  the  patient,  which  was  connected  with  a  second  manometer, 
writing  on  the  lyudwig  kymograph.  The  advantage  of  the  pneu- 
mograph over  this  method  must  be  apparent. 

The  author's  first  results  appeared  in  print  three  months  before 
those  of  Moritz  in  the  "Zeitschrift  fiir  Biologic,"  Bd.  xxxii,  which 
are  perhaps  the  most  important  contributions  to  the  physiology  of 
the  motor  function  since  the  investigations  of  Hofmeister  and  Schiitz 
("Archiv  f.  exper.  Pathol,  und  Pharm.,"  1886,  Bd.  xx).  In  order 
that  the  mechanism  of  the  gastric  peristalsis  may  be  better  under- 
stood, it  is  well  to  bear  in  mind  the  arrangement  of  the  muscular 
layers, — (i)  longitudinal,  (2)  oblique,  and  (3)  circular, — and  what 
was  said  under  the  head  of  anatomy  of  the  gastric  layers  and  the 
formation  of  the  sphincter  of  the  pylorus.  The  part  of  the  stomach 
near  the  pyloric  end  is  spoken  of  more  specifically  as  the  antrum 
pylori. 

The  line  of  separation  between  the  antrum  pylori  and  the  body 
or  fundus  of  the  stomach  is  made  by  a  special  thickening  of  the 
circular  fibers,  forming  what  is  spoken  of  as  the  transverse  band  by 
older  writers — for  instance,  Beaumont,  in  his  ' '  Physiology  of  Diges- 
tion," second  edition,  1847,  page  104.  (A  pioneer  piece  of  work, 
very  fundamental  and  thorough  in  its  observations,  this  book  re- 


PHYSIOLOGY   OF    GASTRIC    MOVEMENTS.  87 

mains  a  monument  to  American  physiological  and  clinical  observa- 
tion.) Recent  observers  describe  this  transverse  band  as  the  sphinc- 
ter antri  pyloric!,  and  locate  it  at  a  distance  of  seven  to  ten  cm.  from 
the  pylorus. 

In  the  antrum  pylori  there  is  a  very  strong  musculature,  and  its 
glands  contain  only  (or  rather  mostly)  chief,  central,  or  ferment 
cells.  The  exact  character  of  the  gastric  movements  during  diges- 
tion were  first  carefully  studied  on  the  human  being  by  Beaumont; 
his  facts  and  errors  have  influenced  physiologists  more  or  less  up 
to  the  present  time.  One  can  not  fail  to  suspect  that  the  stomach 
of  Alexis  St.  Martin  and  its  manner  of  peristalsis  were  too  far  from 
the  normal  to  permit  absolutely  correct  conclusions.  The  extensive 
adhesions  which  Beaumont  describes  certainly  acted  at  times  as 
irritants,  at  others  as  impediments,  to  normal  peristalsis. 

Professor  W.  H.  Howell's  views  on  the  gastric  movements,  as 
expressed  in  the  "American  Text-book  of  Physiology,"  page  317, 
will  serve  as  an  expression  of  a  modern  physiologist.  He  says 
{loc.  cit.)  the  movements  occur  in  two  phases:  "First,  the  feeble 
peristaltic  movement  running  over  the  fundus,  chiefly  on  the  side 
of  the  great  curvature,  and  resulting  in  pushing  the  fundic  contents 
into  the  antrum;  secondly,  the  sharp  contraction  of  the  sphincter 
antri  pylorici,  followed  by  a  similar  contraction  of  the  entire  mus- 
culature of  the  antrum,  both  circular  and  longitudinal,  the  effect 
of  which  is  to  squeeze  some  of  the  contents  into  the  duodenum, 

"It  is  possible  that  either  of  these  phases,  especially  the  first, 
might  occur  at  times  without  the  other,  and  in  the  first  phase  it  is 
possible  that  the  longitudinal  fibers  of  the  stomach  also  contract, 
shortening  the  organ  in  its  long  diameter,  and  aiding  the  propulsive 
movement,  but  actual  observation  of  this  factor  has  not  been  suc- 
cessfully made.  It  can  well  be  understood  that  a  series  of  these 
movements  occurring  at  short  intervals  would  result  in  putting  the 
entire  semiliquid  contents  of  the  stomach  into  constant  circulation. 

"The  precise  direction  of  the  current  set  up  is  not  agreed  upon, 
while  it  is  probable  that  the  graphic  description  given  by  Beaumont 
is  substantially  accurate.  A  portion  of  this  description  may  be 
quoted  as  follows;  'The  ordinary  course  and  direction  of  the  revo- 
lutions of  food  are,  first,  after  passing  the  esophageal  ring,  from 
right  to  left,  along  the  small  arch;  thence,  through  the  large  curva- 
ture, from  left  to  right.  The  bolus,  as  it  enters  the  cardia,  turns 
to  the  left,  passes  the  aperture,  descends  into  the  splenic  extremity. 


88  METHODS    FOR   TESTING    GASTRIC    PERISTALSIS. 

and  follows  the  great  curvature  into  the  pyloric  end ;  it  then  returns 
in  the  course  of  the  small  curvature.' 

"The  average  time  taken  for  one  of  these  complete  revolutions, 
according  to  observations  made  by  Beaumont,  seems  to  vary  from 
one  to  three  minutes. 

"It  is  possible,  of  course,  that  this  typical  circuit  taken  by  food 
may  often  be  varied,  more  or  less,  by  different  conditions,  but  the 
muscular  movements  observed  from  the  outside  would  seem  to  be 
adapted  to  keeping  up  a  general  revolution  of  the  kind  described. 
The  general  result  upon  the  food  may  be  easily  imagined.  It  be- 
comes thoroughly  mixed  with  the  gastric  juice  and  any  liquid  which 
may  have  been  swallowed,  and  is  gradually  disintegrated,  dissolved, 
and  more  or  less  completely  digested,  so  far  as  the  proteid  and 
albuminoid  constitu tents  are  concerned. 

"The  mixing  actions  are  aided,  moreover,  by  the  movements  of 
the  diaphragm  in  respiration,  since  at  each  descent  it  presses  upon 
the  stomach.  The  powerful  muscular  contractions  of  the  antrum 
serve  also  to  triturate  the  softened  solid  particles,  and  finally  the 
whole  mass  is  reduced  to  a  liquid  or  semiliquid  condition,  in  which 
it  is  known  as  chyme,  and  in  this  condition  the  rhythmic  contractions 
of  the  muscles  of  the  antrum  eject  it  into  the  duodenum. 

"The  rhythmic  spurting  of  the  contents  of  the  stomach  into  the 
duodenum  has  been  noticed  by  a  number  of  observers,  through 
duodenal  fistulae  in  dogs,  established  just  beyond  the  pylorus.  It 
has  been  shown,  also,  that  when  the  food  is  entirely  liquid, — water, 
for  example, — the  stomach  is  emptied  in  a  surprisingly  short  time 
— within  twenty  or  thirty  minutes;  if,  however,  the  water  is  taken 
with  solid  food,  then,  naturally,  the  time  it  will  remain  in  the  stomach 
may  be  much  lengthened." 

Brinton  ("Diseases  of  the  Stomach")  advanced  the  view,  which 
differs  from  Beaumont's,  in  assuming  a  central  current  of  the  food, 
moving  from  the  pylorus  to  the  cardia  through  the  central  long 
axis  of  the  stomach.  There  are,  according  to  this  author,  two  cur- 
rents, one  along  each  curvature  running  from  the  cardia  to  the 
pylorus,  meeting  and  turning  inward  toward  the  center  of  the  stom- 
ach in  front  of  the  pylorus,  and  then  running  back  toward  the  esoph- 
agus as  a  single  central  current,  there  dividing  to  make  again  two 
currents  as  before,  one  along  each  curvature. 

According  to  Poensgen  ("Die  Motor.  Verricht.  des  menschl. 
Magens,"  Strassburg,  S.  82),  Reymond,  Donders,  and  Lesshaft  ap- 


THEORIES    OF    BEAUMONT   AND    BRINTON.  89 

proved  of  this  theory;  while  Penzoldt  and  Foster  accept  the  great 
food-circle  of  Beaumont. 

Although  we  have  made  over  fifty  experiments  on  dogs,  cats,  and 
rabbits  to  observe  a  food-circulation  within  the  stomach  correspond- 
ing to  these  views,  and  although  we  have  had  an  opportunity  of 
seeing  into  the  human  stomach,  through  fistulas,  during  digestion, 
we  have  not  been  able  to  confirm,  by  actual  observation,  either 
Beaumont's  or  Brinton's  views.  While  we  have  no  new  explana- 
tions to  offer,  it  has  occurred  to  us  that  the  piston-like  backward 
and  forward  movements  of  the  food  caused  by  the  antral  contrac- 
tions, and  especially  of  the  sphincter  of  the  antrum,  is  a  sufiicient 
force  to  effect  the  mixture  of  the  chyme  with  HCl  and  the  ferments 
such  as  are  found  in  it  when  it  leaves  through  the  pylorus.  The 
movements  do  not  differ  essentially  from  those  observed  in  the  cat 
by  Cannon  ("Amer.  Journ.  Physiol.,"  vol.  i). 

The  views  of  Beaumont  and  Brinton  date  from  the  epoch  when 
it  was  considered  all-important  that  food  must  be  properly  digested 
and  macerated  in  the  stomach;  it  was  not  conceivable  then  that  by 
far  the  main  bulk  of  digestion  is  carried  on  in  the  intestines.  Hence 
the  complicated  theories  of  Beaumont  and  Brinton,  of  circular 
movements  of  food,  owe  their  origin  to  the  thought  that  such  a 
movement  was  necessary  to  mix  the  ingesta  with  the  gastric  juice. 
In  dogs  this  mixture  is  not  proved  to  occur  in  every  instance.  In 
herbivora  (horse,  cow)  the  center  of  the  food-mass  in  the  stomach 
may  be  alkaline  or  neutral  in  animals  killed  one  hour  and  a  quarter 
after  feeding. 

The  almost  vertical  position  of  the  stomach  was  unknown  to 
Beaumont  and  Brinton.  Tike  many  clinicians  of  the  day,  they 
believed  the  organ  was  normally  in  a  horizontal  position,  trans- 
versely across  the  upper  part  of  the  abdomen.  The  amount  of  force 
required  to  lift  the  food-mass  in  a  vertical  line  upward  is  consider- 
able; it  is  necessary  to  imagine  a  still  greater  force  to  accomplish 
the  vertical  ascent  on  the  side  of  the  lesser  curvature,  in  order  to 
conceive  of  a  simultaneous  descent  on  the  side  of  the  great  curvature, 
which  descending  current  must  inevitably  interfere  more  or  less 
with  the  ascending  one. 

In  a. number  of  experiments  in  which  the  stomachs  of  animals 

on  opening  the  abdomen  were  found  in  active  motion,  we  inserted 

long  needles  through  the  gastric  walls  to  determine  the  direction 

they  would  assume  under  the  pressure  of  the  ingesta.     According 

7 


90  METHODS    FOR   TESTING    GASTRIC   PERISTALSIS. 

to  Beaumont,  the  ingesta  moving  from  the  saccus  csecus  along  the 
greater  curvature  to  the  pylorus  should  compel  the  points  of  needles 
to  be  directed  toward  the  pylorus  when  run  through  the  greater 
curvature,  and  along  the  lesser  curvature  they  should  point  toward 
the  cardia. 

If  Brinton's  theory  were  true,  the  points  of  the  needles  at  both 
curvatures  should,  at  least  during  a  large  period  of  gastric  digestion, 
be  directed  toward  the  pyloric  end.  If  needles  are  inserted  to  a 
distance  of  yi  of  an  inch  along  both  cur^^atures  during  active  gastric 
peristalsis,  a  great  diversity  of  movements  of  the  outside  portions 
of  the  needles  is  observable.  They  very  rarely  point  the  same  way 
along  either  curvature,  and  one  portion  of  them  may  point  toward 
the  cardia,  while  another  points  to  the  pylorus.  Only  when  the 
needles  are  inserted  very  deep,  so  that  they  dip  into  the  central  or 
axial  stream,  can  one  occasionally  obser^^e  what  appears  as  con- 
certed action. 

During  active  peristalsis,  when  the  preantral  sphincter  at  times 
contracts  so  powerfully  as  almost  to  obliterate  the  lumen,  those 
needles  inserted  into  the  fundic  portion  of  both  the  greater  and 
lesser  curvatures  are  strongly  turned  toward  the  cardia,  but  simul- 
taneously those  few  needles  in  the  antral  and  pyloric  portions  are 
turned  toward  the  duodenum.  The  same  evidence  of  a  central  or 
axial  current,  which  indicates  the  pumping  work  of  the  muscular 
antrum  in  pushing  back  solid  particles  into  the  fundus,  and  squeez- 
ing liquid  and  semiliquid  portions  into  the  duodenum,  can  be 
obtained  by  the  intragastric  electric  lamp  when  introduced  during 
the  height  of  gastric  digestion.  These  lamps  can  be  seen  through 
the  abdominal  wall  in  dogs  whose  abdomens  have  been  shaved,  when 
introduced  in  a  dark  room,  though  naturally  not  quite  so  distinct  as 
when  the  abdomen  is  opened. 

The  author  has  studied  gastric  peristalsis  in  the  human  subject 
by  means  of  the  X-rays.  (The  original  method  was  described  in  the 
"Boston  Medical  and  Surgical  Journal,"  June  i8,  1896,  and  con- 
sisted of  introduction  of  a  distensible  rubber  bag  into  the  stomach. 
The  X-rays  were  cut  off  by  a  coating  of  argentic  oxid  on  the  inner 
side  of  the  bag.) 

A  new  application  of  the  method  of  Boas  and  Levy-Dorn  for 
locating  the  site  of  obstructions  in  the  digestive  canal  by  means  of 
capsules  filled  with  bismuth  subnitrate — which  cut  off  the  X-rays, 
and  are  thus  visible — was  made  by  W.  B.  Cannon  for  the  study  of 


STUDIES    OF    PERISTALSIS    BY   X-RAYS.  9 1 

the  gastric  peristalsis  in  the  cat  ("Amer.  Jour.  Physiol.,"  vol.  i,  p. 
359,  May,  189S).  His  results  are  valuable  as  confirming  other 
recent  experiments,  indicating  that  the  main  peristaltic  work  is 
carried  on  by  the  pyloric  end  of  the  stomach.  This  was  experi- 
mentally demonstrated  by  the  author  with  the  apparatus  pictured 
on  page  So  ("New  York  Med.  Jour.,"  June  22,  1895).  The  fundus 
is  not  capable  of  exciting  effective  contractions.  As  will  be  shown 
further  on,  it  empties  the  ingesta  very  gradually  into  the  pyloric 
antrum;  it  is  more  of  a  reservoir  than  a  food  titrator.  The  mixing, 
titration,  and  expulsion  is  carried  on  by  the  muscular  antrum  pylori. 
In  the  cat  the  stomach  is  emptied  by  the  formation  between  the 
fundus  and  the  antrum  of  a  tube  along  which  constrictions  pass. 
The  contents  of  the  fundus  are  pressed  into  the  tube,  which,  to- 
gether with  the  antrum,  is  slowly  cleared  of  food  by  waves  of  con- 
striction (Cannon,  loc.  cit.).  The  author  has  made  observations  on 
human  subjects  with  thin  abdominal  walls  by  the  method  of  Boas 
and  Levy-Dorn.  Before  the  Rontgen  fay  apparatus  the  capsule 
of  bismuth  subnitrate  could  be  seen  oscillating  backward  and  for- 
ward, sometimes  slowly,  sometimes  with  surprising  rapidity,  until 
it  was  pressed  through  the  pyloric  sphincter,  which  generally  ap- 
peared to  occur  with  a  rush.  But  never  was  any  circuit  of  the 
capsule  observed,  such  as  is  described  by  Beaumont,  Brinton,  or 
adopted  by  W.  H.  Howell.  With  the  method  used  by  Cannon — 
i.  e.,  mixing  subnitrate  of  bismuth  with  the  food — it  is  impossible  to 
judge  of  any  movement  of  individual  particles;  only  the  general 
body  and  contour  of  the  stomach  as  a  whole  become  observable. 
We  agree  with  him  that  the  food  in  the  fundus  is  not  moved  to 
any  considerable  extent  by  peristalsis,  but  his  further  conclusion 
that  it  is  consequently  not  mixed  with  gastric  juice,  may  be  true 
of  the  cat,  but  does  not  apply  to  the  human  being.  Food  drawn 
out  of  the  fundus  by  the  Einhorn  stomach-bucket,  which  can  be 
seen  before  the  X-ray  apparatus,  always  contains  gastric  juice  if 
any  is  secreted  at  all.  In  man  the  antrum  does  not  form  into  a 
tube  as  in  the  cat,  though  an  approach  to  this  formation  is  made; 
during  powerful  contractions  the  impression  is  conveyed  as  though 
a  second  sphincter,  about  ten  cm.  above  the  pylorus,  contracted 
and  shut  off  the  antrum  pylori  from  the  body  of  the  stomach. 

The  author  has  observed  this  axial  food-current  at  the  clinic  in  a 
female  patient  with  very  thin  abdominal  parietes,  when  the  Einhorn 
intragastric  lamp  was  introduced  one  hour  after  a  meal.     In  animals 


92  ME^THODS  FOR  TESTING  GASTRIC   PERISTALSIS. 

with  abdomen  opened  we  have  been  able  to  see  this  lamp  carried 
along  the  entire  greater  curvature,  from  the  pylorus  toward  the 
cardia,  during  active  digestion,  but  the  occurrence  is  so  rare  as  to 
appear  accidental. 

That  the  retrogressive  current,  which  is  set  up  by  contractions 
of  the  antrum  forcing  the  too  solid  food-particles  back  toward  the 
fundus,  must  inevitably  set  up  some  new  movements  among  the 
remaining  food-mass  in  the  fundic  end  is  natural,  but  we  have  no 
evidence  that  it  ever  reaches  that  systematic  circulation  described 
first  by  Beaumont  and  Brinton. 

It  should  not  be  overlooked  that  if  the  observations  of  Beaumont 
of  a  complete  food-circuit  were  really  true  and  constituted  the  only 
movements  in  addition  to  the  duodenal  extrusion  which  the  food- 
mass  underwent,  there  must  always  be  a  mass  of  food  in  the  center  of 
the  stomach  which  never  touches  the  gastric  wall ;  if  all  the  food  moves 
about  along  the  periphery,  there  must  be  a  central,  quiet  portion. 

Brinton  was  aware  of  this  defect  in  Beaumont's  statements,  and 
improved  upon  them  by  his  still  more  complicated  theory  of  piston 
movements  and  central  current  to  explain  the  axial  food-motions. 

If  the  conditions  described  by  these  authors  exist,  they  are  not 
well  explained  by  the  arrangement  of  the  muscularis  of  the  fundus, 
which,  as  far  as  the  work  of  Meltzer  (loc.  cit.),  Moritz  {loc.  cit.), 
Goldschmidt  {loc.  cit.)  and  the  author  show,  is  very  feeble  indeed  in 
its  contractions,  and  hardly  sufficient  to  propel  food  in  any  direc- 
tion; yet,  according  to  the  above  theory,  powerful  contractions  are 
ascribed  to  it;  but  as  the  preantral  sphincter  is  only  seven  to  ten 
cm.  from  the  pylorus,  it  certainly  can  not  be  made  accountable  for 
the  movements  all  around  the  cardia  and  the  saccus  csecus. 

The  musculature  of  the  fundic  end  has  never  been  observed  in 
peristaltic  motion  by  us,  excepting  the  peristalsis  occasionally  arising 
from  the  antrum  and  traveling  upward  over  it.  During  active 
peristalsis  it  is  in  a  condition  of  tonic  contraction  with  the  intra- 
gastric bag  in  the  fundus ;  we  have  estimated  this  to  be  equal  to  six 
to  eight  cm.  of  water  (water  manometer). 

Moritz,  in  his  work  on  "The  Motor  Function  of  the  Stomach," 
studiously  avoids  referring  to  any  systematic  food-circulation  within 
the  organ.  It  seems  rational  that  sufficient  churning  and  mixing 
is  effected  by  the  powerful  contractions  of  the  antrum  during  the 
general  tonus  of  the  fundus  to  explain  the  saturation  and  softening 
of  the  ingesta  by  gastric  juice. 


CONCLUSIONS    CONCERNING   PHYSIOLOGY    OF    PERISTALSIS.         93 

The  contrasting  relations  of  the  fundus  and  antrum  regarding 
active  peristalsis  are  evident  in  the  degree  of  pressure,  as  observed 
on  a  water  manometer  in  connection  with  our  triple  intragastric 
bag.  In  the  fundus  the  pressure  is,  on  an  average,  equal  to  three 
to  six  cm.  of  water.  The  increase  of  intragastric  pressure  due  to 
cardiac  action  is  equal  to  one  to  two  cm.  (In  this  is  included  the 
pressure  due  to  every  new  heart  impulse  and  aortic  impulse.)  The 
inspiratory  increase  of  pressure  is  equal  to  six  to  twelve  cm.  These 
are  very  nearly  the  figures  Moritz  obtained,  and  we  add  them  here 
as  merely  in  support,  and  confirmatory,  of  his  views. 

Conclusions. — It  is  necessary  to  distinguish  the  movements  of 
the  (i)  fundus,  (2)  preantral  portion,  (3)  antrum,  and  (4)  pyloric 
sphincter,  (i)  The  motor  apparatus  of  the  stomach  is  represented 
by  its  muscular  fibers.  Where  these  are  most  developed,  the  peri- 
stalsis is  strongest;  where  they  are  least  developed,  it  is  weakest. 
(2)  The  fundus  has  a  thin  muscular  development,  hence  its  peri- 
stalsis is  insignificant,  and  consists  in  squeezing  its  contents  into  the 
tubular  preantmm  or  prepyloric  portion.  (3)  Waves  of  constriction 
along  the  preantrum  press  the  food  forward  and  backward  through 
this  portion  until  a  mightier  wave-impulse  sweeps  it  into  the  mus- 
cular ampulla  just  in  front  of  the  pylorus,  the  antrum  pylori.  (4) 
The  final  expression  into  the  duodenum  is  executed  by  the  antrum, 
which  may  contract  as  a  whole  or  form  into  two  spherical  muscular 
ventricles  by  a  constriction  (rarely).  (5)  A  food  circulation,  in  the 
sense  of  Beaumont  and  Brinton,  does  not  occur. 

The  physiology  of  the  motor  function  has  been  dwelt  upon  more 
extensively  than  seems  necessary  in  a  condensed  statement  of  gastric 
pathology,  not  only  because  it  is  the  most  important  ofifice  of  the 
stomach,  but  because  we  have  become  convinced  that,  in  a  large 
majority  of  disorders  of  secretion  and  absorption,  an  abnormality 
in  the  motor  function  lies  at  the  foundation. 

The  exaggerated  or  diminished  peristalsis  can  on  careful  exam- 
ination be  detected  sometimes  before  the  secretory  and  absorptive 
anomalies  are  apparent.  The  secretory  disturbances  observed  after 
section  of  both  vagi  are  due,  according  to  Contejean,  to  the  motor 
paralysis  caused  at  the  same  time  ("Archiv.  de  Physiologic,"  vol. 
IV,  p.  640).  A  similar  view  is  held  by  H.  Borutteau  ("Phliiger's 
Archiv,"  Bd.  Lxv,  p.  26). 

The  relation  between  motility  and  secretion  and  absorption  is  not 
at  all  well  understood.     The  peristaltic  movements  effecting  a  chum- 


94  ABSORPTION    FROM   THE)    STOMACH. 

ing  motion  are  those  mostly  concerned  in  stimulating  secretion; 
when  these  movements  are  lost,  secretion  is  generally  disturbed. 

The  last  vestige  of  peristalsis  is  that  by  which  the  stomach  is 
emptied,  and  it  may  be  present  with  total  absence  of  secretion. 
In  stomachs  with  motility  much  impaired  and  secretion  arrested, 
the  absorptive  function  is  greatly  reduced  (atrophic  gastritis,  car- 
cinoma). In  temporary  arrests  of  these  functions,  the  secretive  and 
absorptive  functions  generally  return  with  improved  motility. 

In  our  drawing  (frontispiece),  the  manner  in  which  the  deep  ends 
of  the  fundus  glands  are  encircled  by  fibers  from  the  muscularis 
mucosae  is  very  evident.  From  this  it  is  conceivable  that  the  func- 
tion of  the  gland-cells  is  in  a  manner  dependent  upon  the  contrac- 
tility of  the  fibers  of  the  muscularis  mucosae,  which  can  not  fail  to 
influence  the  blood-supply  to  these  cells  (see  Mall,  on  "Circulation 
in  the  Dog's  Stomach,"  chap.  i). 


CHAPTER  X. 
ABSORPTION  FROM  THE  STOMACH. 

Penzoldt's  and  Faber's,  Herschel's,  Julius  Miller's,  and  Hemmeter's 
Tests  for  Gastric  Resorption. 

Remarkable  variations  exist  in  the  absorptive  power  of  the  gas- 
tric mucosa,  not  only  in  different  animals,  but  in  the  same  animals 
at  different  times  and  under  varying  conditions.  Absorption  is 
largely  influenced  by  gastric  innervation  and  the  quality,  quantity, 
and  pressure  of  blood-supply.  Bdkins  in  1892  ("Journ.  of  Physiol.," 
p.  460)  pubhshed  experiments  in  which  he  introduced  a  measured 
quantity  of  salt  solution  into  the  stomach  of  cats  after  ligation 
of  the  pylorus  and  the  cardia;  after  an  hour  he  recovered  exactly 
the  same  quantity  again.  We  have  already  referred  to  the  work 
of  von  Mehring  ("Therap.  Monatshefte,"  1893),  which,  like  that 
of  Edkins,  shows  that  water  is  not  absorbed  from  the  stomach. 
Peptone,  grape-,  milk-  and  cane-sugars,  maltose,  dextrin,  and  alcohol 
are  absorbed,  and  von  Mehring  demonstrated  that  a  more  or  less 
active  secretion  of  water  from  the  walls  into  the  stomach  occurred 
simultaneously  with  the  absorption,  so  that  in  his  dogs  with  duo- 


ABSORPTION    OF    STRYCHNIN.  95 

denal  fistulas  he  found  a  larger  quantity  of  water  came  out  through 
the  fistula  than  the  dogs  had  taken  by  the  mouth.  Bouley  and 
Colin  (Colin,  "Traite  de  physiologie  comparee,"  vol.  ii,  p.  91)  intro- 
duced strychnin  into  the  stomach  of  animals  after  ligation  of  the 
pylorus — or  after  it  was  paralyzed  (as  they  claim)  by  vagotomy. 
It  is  stated  by  them  that  the  effect  of  strychnin  was  rapidly  evident 
in  the  cat,  dog,  and  pig,  that  it  was  retarded  in  the  cow,  and  that  there 
was  no  effect — at  least,  no  serious  effect — in  the  horse.  Tappeiner 
("Ueber  Resorption  im  Magen,"  "Zeitschr.  f.  Biol.,"  1880)  intro- 
duced strychnin  into  the  stomach  of  cats;  0.03  gm.  of  this  alkaloid 
in  an  aqueous  solution  was  sufficient  to  kill  a  cat  weighing  two 
kilos  in  eight  minutes.  Cats  whose  pylorus  was  tied  succumbed  to 
doses  of  0.05  gm.  and  more  only  after  an  hour  and  thirty  minutes  or 
even  later.  When  the  strychnin  solution  contained  alcohol,  it  was 
absorbed  almost  as  rapidly  as  when  the  pylorus  was  not  li gated. 
Similarly,  chloral  hydrate  was  not  absorbed  in  aqueous  solution,  but 
readily  in  alcoholic  solution,  from  the  stomachs  of  dogs  whose  pylorus 
was  ligated. 

In  the  experiments  of  Meltzer  on  the  absorption  of  strychnin  and 
hydrocyanic  acid  from  the  stomach  of  rabbits  ("Journ.  Exper. 
Med.,"  vol.  I,  p.  529),  it  was  found  that  six  to  ten  milligrams  of  strych- 
nin introduced  into  the  full  stomach  with  the  pylorus  open  would 
rapidly  bring  on  tetanus,  and  it  is  intimated  that  absorption  takes 
place  in  that  case  from  the  intestines,  not  from  the  stomach.  When 
the  pylorus  is  closed,  even  such  large  doses  as  200  milligrams  of 
strychnin,  remaining  for  many  hours  within  the  empty  stomach, 
with  good  circulation  and  with  intact  innervation  of  the  vagi,  do 
not  produce  any  effect  at  all.  The  conclusion  is  justifiable  that  the 
gastric  mucosa  does  not  absorb  strychnin  to  any  considerable  ex- 
tent. From  Meltzer's  experiments,  which  apply  only  to  rabbits, 
it  is  not  evident  that  the  circulation  of  the  stomach  was  good,  for 
when  the  pylorus  or  the  cardia  is  ligated,  a  normal  gastric  circula- 
tion becomes  impossible.  Injection  of  strychnin,  stained  with  methyl- 
ene-blue,  into  the  submucosa  {loc.  cit.),  which  was  in  two  minutes 
followed  by  tetanus,  although  the  cardia  was  tied  and  a  tube  tied 
into  the  pylorus,  does  not  prove  that  the  circulation  was  normal. 
The  same  objections  as  can  be  brought  against  the  experiments 
of  Talma  {loc.  cit.)  are  applicable  to  Meltzer's;  the  method  con- 
stitutes too  violent  an  interference  with  gastric  circulation  and 
peristalsis.     The  author  has,  however,  been  able  to  confirm  Meltzer's 


96  ABSORPTION   FROM    THE)   STOMACH. 

conclusions,  for  in  rabbits  in  whom  the  pylorus  was  occluded  by  a 
rubber  balloon  introduced  through  the  mouth  and  stomach  and 
blown  up  in  the  duodenum  just  beyond  the  pylorus,  it  was  discovered 
that  strychnin  is  not  absorbed  from  the  stomach.  Stenosing  the 
outlet  beyond  the  pylorus  does  not  in  any  way  injure  the  stomach 
nor  disturb  circulation  or  innervation.  The  rabbit  is  not  free  from 
objection  as  an  experimental  animal,  as  its  gastric  mucosa  is  rarely 
in  an  entirely  normal  condition.  Meltzer  found  that  distinct  dif- 
ferences exist  in  the  absorptive  power  of  different  parts  of  the  diges- 
tive tract;  for  instance,  the  mucous  membrane  of  the  esophagus 
absorbs  strychnin  very  poorly.  The  part  of  the  ahmentary  canal 
absorbing  best  is  the  pharynx;  the  rectum  absorbs  strychnin  next 
best,  its  resorptive  power  excelHng  that  of  the  small  intestine.  Prus- 
sic  acid  is,  however,  absorbed  very  well  from  the  stomach  even  when 
the  pylorus  is  ligated ;  it  seems  to  produce  a  hemorrhagic  surface  on 
the  mucous  membrane  which  facilitates  absorption. 

The  method  most  commonly  employed  to  test  gastric  resorption 
is  that  of  Penzoldt  and  Faber.  Three  to  five  grains  of  iodid  of 
potassium  are  inclosed  in  a  gelatin  capsule,  which  is  administered 
with  100  c.c.  =  3^  ounces  of  water.  Iodid  of  sodium  or  potassium, 
when  taken  internally,  will  appear,  and  can  be  tested  for  in  the 
saliva  and  in  the  urine,  where  it  is  excreted  in  from  six  and  one-half 
to  fifteen  minutes. 

The  test  is  generally  made  by  wetting  starch  paper  with  the  saliva 
of  the  patient  every  two  minutes  after  the  KI  is  taken,  and  touching 
the  wet  spot  with  fuming  nitric  acid.  The  first  appearance  of  a 
blue  color  indicates  that  the  iodid  has  reached  the  point  of  excretion, 
and  consequently  must  have  been  absorbed.  If  this  reaction  first 
occurs  after  fifteen  minutes,  then  the  rate  of  absorption  is  reduced. 
This,  according  to  Zweifel  ("Resorpt.  Verhaltnisse  d.  menschl. 
Magens,"  "Deutsch.  Arch.  f.  klin.  Med.,"  Teipsic,  Bd.  xxxix,  p. 
349,  1886),  occurs  in  gastritis,  dilatation,  and  carcinoma;  in  gastric 
ulcer  the  resorption  is  said  to  be  normal,  or  nearly  so. 

Most  authorities  (J.  Wolff,  Zweifel,  Sticker,  Quetsch)  differ  very 
much  on  this  question,  but  agree  on  the  reduced  absorption  in 
carcinoma.  If  the  iodid  is  given  during  a  meal,  the  reaction  occurs 
much  later.    . 

Herschel  ("Indigestion,"  London,  1895,  p.  115)  estimates  the 
absorptive  power  by  giving  two  decigrams  of  powdered  rhubarb, 
which  gives  a  red  color  in  the  urine  with  liquor  potassa^  normally 


zweifkl's  absorption  experiments.  97 

in  fifteen  minutes.  Our  experience  with  this  method  is  that  fre- 
quently the  urine  is  so  highly  colored  in  digestive  diseases  that  the 
red  color  must  be  very  decided  to  be  recognized — in  addition  to 
which  it  sujffers  from  the  same  objection  as  Penzoldt's  and  Faber's 
method.  In  the  first  place,  Brandl's  experiments  have  shown  that 
sodium  iodid  is  absorbed  to  a  very  sUght  degree  or  not  at  all  in 
dilute  solutions. 

Not  until  its  solutions  reach  a  concentration  of  three  per  cent, 
or  more  does  its  absorption  become  important.  Accordingly,  all 
soluble  inorganic  salts  are  practically  not  absorbed  in  the  stomach, 
since  it  can  not  be  supposed  that  they  are  normally  swallowed  in 
solutions  so  concentrated  as  three  per  cent.  Brandl  also  found  that 
condiments,  such  as  mustard  and  pepper,  and  also  alcohol,  very  much 
facilitated  the  absorption  of  sodium  iodid.  Perhaps,  these  substances 
act  by  stimulating  the  epitheHal  cells,  or  by  causing  a  marked  hyper- 
emia of  the  mucosa. 

The  absorption  time  does  not  vary  much  in  the  same  individual, 
except  when  the  stomach  is  full ;  in  this  case  it  is  not  only  prolonged, 
but  is  very  variable  in  the  same  individual.  This  prolongation, 
according  to  Sidney  Martin  ("Diseases  of  the  Stomach,"  London, 
1895),  is  probably  due  to  a  considerable  dilution  of  the  iodid  by 
the  stomach  contents,  and  also  to  the  fact  that  the  salivary  glands 
are  not  so  active  after  a  meal  as  in  the  fasting  condition.  One  must 
not  overlook  the  fact  in  these  experiments  that  it  is  not  only  the 
absorptive  activity  of  the  stomach  that  is  being  investigated,  but 
also  the  excretory  activity  of  the  salivary  glands. 

In  Zweifel's  experiments  it  is  probable,  from  what  we  know  of 
the  absorption  of  water  in  the  stomach,  through  the  observations 
of  Tappeiner  ("Ueber  Resorption  im  Magen,"  "Zeitschr.  f.  Biol.," 
Miinchen,  Bd.  xvi,  p.  497,  1881)  and  von  Mehring  {loc.  cit.),  that 
most  of  the  liquid  containing  the  iodid  passes  rapidly  into  the  duo- 
denum. Therefore,  we  may  be  testing  not  only  gastric  absorption 
and  excretory  activity  of  the  salivary  glands,  but  also  intestinal 
absorption. 

Zweifel  concludes  {loc.  cit.)  that  in  all  diseases  of  the  stomach 
there  is  a  prolongation  of  absorption  time,  which  is  greatest  in  dila- 
tation and  carcinoma  and  least  in  chronic  gastric  catarrh,  and  very 
slight  in  ulcer  in  the  later  stages;  in  the  early  stages  of  ulcer,  how- 
ever, he  claims,  the  rate  of  absorption  is  also  prolonged.  . 

It  is  very  evident  that  no  differentiation  between  catarrh  and 


98  ABSORPTION   FROM   THE   STOMACH. 

ulcer  is  possible  according  to  this  method,  and  thereby  one  of  the 
main  purposes  of  such  investigations — that  of  aiding  in  the  estab- 
lishment of  a  diagnosis — is  thwarted. 

In  view  of  these  defects,  which  apply  equally  well  to  Herschel's, 
Penzoldt's,  and  Faber's  methods  of  testing  absorption,  and  are 
caused  mainly  by  the  fact  that  water  is  not  absorbed  from  the  stom- 
ach, and  that  the  varying  secretory  activity  of  the  salivary  glands 
and  kidneys  is  a  factor  influencing  absorption  time,  we  have  devised 
a  method  which  is  available  for  experiments  on  gastric  absorption 
in  the  physiological  laboratory,  and  which  we  have  successfully  tried 
on  six  male  and  eight  female  patients  and  ten  healthy  students. 
The  methods  of  testing  the  urine  and  saliva  were  discarded  entirely. 

Our  method  consists  in  washing  out  the  stomach  thoroughly; 
then,  by  means  of  our  method  of  duodenal  intubation,  the  entrance 
into  the  duodenum  is  plugged,  or  closed  up,  by  introducing  a  small 
rubber  balloon  into  it  and  blowing  it  up  in  front  of  or  beyond  the 
pylorus.  (A  method  having  the  same  object  in  view  has  been 
described  subsequent  to  the  author's  publication,  by  Dr.  F.  Kuhn, 
in  the  "Miinchener  medizin.  Wochenschr.,"  Nos.  27,  28,  and  29, 
1896,  but  it  is  founded  upon  a  different  principle  from  ours — the 
spiral  sound.) 

After  thus  mechanically  closing  the  pylorus,  a  weighed  amount 
of  any  of  the  substances  which  von  Mehring  has  shown  are  readily 
absorbed,  or  of  any  harmless  inorganic  salt, — sodium  chlorid  or 
sodium  phosphate, — dissolved  in  100  c.c.  of  distilled  water,  so  as  to 
make  a  three  per  cent,  solution,  is  poured  into  the  organ  through 
a  tube.  This  is  indispensable  to  exclude  loss  of  the  salt  solution 
through  clinging  to  the  tongue,  mouth,  and  esophagus  or  absorption 
from  these  tissues. 

After  a  lapse  of  ten  minutes  the  fluid  is  again  drawn  out  of  the 
stomach  by  aspiration,  or  even,  if  necessary,  by  adding  known  quan- 
tities of  distilled  water,  until  the  last  washing  gives  no  indication 
of  containing  any  trace  of  the  salt  by  a  proper  chemical  test.  This 
entire  water  is  now  evaporated  to  dryness  and  the  residue  weighed. 
The  difference  between  the  amount  of  NaCl  poured  into  the  stomach 
— which  in  a  three  per  cent,  solution  is  three  gm.  in  case  100  c.c. 
are  used — and  the  amount  regained  indicates  the  degree  of  gastric 
absorption. 

To  simplify  matters,  the  practical  suggestion  of  Julius  Miller 
(Boas'  "Archiv  fiir  Verdauungskrankheiten,"  Bd.  i,  p.   237,   "Zur 


miller's  method  for  testing  absorption.  99 

Kennt.  d.  Sek.  u.  Resorpt.  im  menschl.  Magen")  has  been  utilized 
and  can  be  recommended.  It  consists  in  noting  the  specific  gravity 
of  salt  solutions  before  pouring  them  through  the  tube,  and  after 
any  desired  time,  the  solutions  are  washed  out  or  aspirated,  and 
the  specific  gravity  again  determined. 

The  difference  between  these  specific  gravities  taken  before  the 
salt  solution  enters  the  stomach  and  after  it  is  regained  affords  a 
satisfactory  index  of  the  rate  of  absorption  from  the  stomach  if  es- 
cape of  the  solution  into  the  duodenum  is  prevented.  It  is  not  nec- 
essary to  evaporate  the  whole  solution  to  dryness  in  case  sodium 
chlorid  or  any  other  harmless  neutral  salt  is  used.  But  after  meas- 
uring the  total  quantity  of  liquid  regained, — say,  for  instance,  it 
amounts  to  one  liter  (looo  c.c), — the  amount  of  NaCl  in  ten  c.c.  can 
be  determined  by  evaporation  in  platinum,  and  the  weight  of  the 
total  remaining  NaCl  calculated  by  multiplying  the  result  by  lOo, 
or  whatever  the  figure  may  happen  to  be. 

This  method  of  determining  the  rate  of  gastric  absorption  gives 
approximately  accurate  results,  even  without  duodenal  intubation 
and  mechanical  closing  of  the  pylorus,  provided  that  by  several 
preliminary  experiments  the  motility  of  the  patient's  stomach  has 
been  relatively  determined. 

By  observing  what  portion  of  500  c.c.  of  water  he  will  pass  into 
the  duodenum  in,  say,  ten  to  twenty  minutes, — this  also  requiring 
the  drawing  out  again  of  the  remnant  of  the  500  c.c.  of  water  that 
was  taken  in  for  experiment, — von  Mehring  {loc.  cit.)  found  that  of 
500  c.c.  of  water  given  to  a  large  dog,  through  the  mouth,  the  entire 
amount,  or  at  least  495  c.c,  had  been  passed  out  of  the  stomach 
through  a  duodenal  fistula  within  twenty-five  minutes. 

In  the  human  being  the  passage  of  water  out  of  the  stomach  is 
not  nearly  so  rapid.  Julius  Miller  {loc.  cit.)  found  that  the  human 
stomach  was  not  rid  of  even  200  c.c.  NaCl  solution  of  the  specific 
gravity  1028  in  thirty  minutes.  After  this  time  he  regained  in  one 
case  75  c.c. ;  sometimes  he  regained  more  liquid  than  he  poured  in. 

In  thirty  tabulated  measurements  which  he  gives  with  sodium 
chlorid  solution  (p.  240,  loc.  cit.),  he  regained  more  than  he  poured  in, 
five  times ;  the  same  amount,  once ;  and  a  less  quantity,  twenty-five 
times.  ,  But  his  figures  go  to  prove  that  even  with  an  open  passage 
into  the  duodenum,  comparatively  small  amounts  of  salt  solutions 
are  passed  out  in  fifteen  minutes. 

Hence,  if  in  any  individual  the  average  amount  passing  into  the 


lOO  ABSORPTION   FROM   THE)    STOMACH. 

duodenum  in  fifteen  minutes  is  known  by  previous  experiments, 
the  closing  of  the  pylorus  is  not  necessary  to  reach  an  approximate 
result  concerning  the  rate  of  absorption.  Miller  confirms  von  Mehr- 
ing's  conclusions  that,  contemporaneous  with  absorption,  a  secre- 
tion of  water  occurs  into  the  stomach. 

This  secretion  increases  with  the  concentration  of  the  solutions. 
In  the  five  instances  mentioned  where  more  was  regained  than  was 
poured  in,  the  specific  gravities,  which  are  a  good  indication  of  con- 
centration, were  1066,  1061,  1052,  1088,  and  1035.  (Regarding 
the  taste  of  three  per  cent,  solution  of  NaCl,  it  might  be  explained 
that  this  is  the  percentage  of  salt  in  the  water  of  the  Atlantic  Ocean, 
which  has  been  recommended  for  internal  use — A.  Levertin,  "Hy- 
gieina,"  XLVii,  xlviii.     "Svenska  lakaresallsk  Forh.,"  S.  138,  1885.) 

In  the  studies  with  occlusion  of  the  pylorus  we  experimented  also 
with  known  solutions  of  sodium  sulphate,  peptone,  maltose,  cane- 
sugar,  milk-sugar,  and  alcohol.  As  water  is  poured  out  on  the  sur- 
face of  the  mucosa,  in  return  for  salts  absorbed,  the  specific  gravity 
will  not  always  instruct  us  as  to  the  contents  of  NaCl,  which  had 
best  be  arrived  at  by  weighing. 

From  experiments  on  animals  it  is  known  that  a  concentrated 
solution  may  cause  the  stomach  to  secrete  water,  thereby  diluting 
it,  but  that  at  the  same  time  it  is  possible  that  there  may  be  ho  re- 
sorption, so  that  weighing  the  residue  from  evaporating  the  liquid 
regained  may  be  unavoidable  for  a  correct  result. 

Maltose  was  found  a  very  practical  substance  for  absorption  ex- 
periments, though  dextrose  will  also  answer  this  purpose,  as  their 
quantity  can  be  readily  determined  in  solution  by  titration  with 
Fehling's  solution,  and  also  by  the  fermentation  test,  for  which  the 
Einhorn  saccharimeter  is  most  serviceable.  Maltose  will  not  reduce 
as  much  Fehling's  solution  as  dextrose,  the  exact  relation  between 
the  two  being,  according  to  Brown  and  Heron,  for  maltose,  60.8; 
for  dextrose,   100. 

According  to  Soxhlet,  one  c.c.  Fehling's  solution  corresponds  to 
7.78  milHgrams  maltose  in  one  per  cent,  solution  (provided  the 
Fehling's  test  was  not  diluted).  Though  maltose  is  converted  into 
dextrose  in  the  stomach,  the  amount  converted  in  ten  to  fifteen 
minutes  is,  according  to  our  observations,  small  enough  to  be  dis- 
regarded. If  desired,  a  test  by  Barfoed's  reagent  may  be  made  to 
detect  if  any  dextrose  is  present  in  the  liquid  regained. 

The  amount  of  sodium  chlorid  in  the  solution  regained  can  also 


PERCUSSION    OF    THE    STOMACH.  lOI 

be  determined  by  titration  (Salkowsky  u.  Leube,  "Die  Lehre  vom 
Harn";  also,  Neubauer  u.  Vogel,  "Analysen  d.  Urins").  The 
metliod  is  given  in  the  laboratory  manual  of  Dr.  Edward  h.  Whit- 
ney ("An  Introduction  into  the  Laboratory  Methods  of  Clinical 
Pathology,"  p.  i8,  Baltimore,  1896).  Our  method  for  absorption 
testing  is,  in  brief,  the  following : 

To  determine  the  amount  of  500  c.c.  of  a  three  per  cent.  NaCl 
solution  passed  into  the  duodenum  in  ten  minutes : 

1.  Allow  500  c.c.  three  per  cent.  NaCl  solution  to  run  into  a  clean 
stomach  through  a  tube  and  remain  ten  minutes. 

2.  Draw  out  as  much  as  possible,  washing  out  the  last  with  known 
quantities  of  distilled  water. 

3.  Determine  the  amount  of  NaCl  as  stated  above,  and  add  the 
average  deficit  of  escape  into  the  duodenum. 

The  difference  between  the  original  amount  NaCl  and  the  amount 
regained  is  a  fairly  accurate  index  of  gastric  absorptive  power;  or, 
by  our  method  of  duodenal  intubation,  occlude  the  pylorus  by 
blowing  up  a  balloon  in  front  of  or  beyond  it ;  pour  into  the  stomach 
through  a  tube  a  known  quantity — say,  100  c.c. — of  a  one  per  cent, 
solution  of  maltose;  in  ten  to  twenty  minutes  aspirate  or  wash  out 
the  amount  of  maltose  left  as  above.  The  deficit  will  indicate  the 
amount  absorbed. 


CHAPTER  XL 

METHODS   FOR    DETERMINING   THE    LOCATION,    SIZE, 
AND  CAPACITY  OF  THE  STOMACH. 

Percussion  and  Palpation. — Gastrodiaphany  of  Einhorn. 

Percussion  of  the  stomach  gives  varying  results,  according  to  its 
contents  and  to  the  degree  of  its  distention.  The  fundus  is  closely 
applied  to  the  concavity  of  the  diaphragm,  and  five-sixths  of  its 
volume  is  to  the  left  of  its  median  line;  only  one-sixth  to  the  right 
(observe  the  accompanying  illustrations  from  Eichhorst's  "Klin. 
Untersuchungs-Methoden").  The  highest  point  is  the  fundus, 
which  reaches  the  level  of  the  ninth  thoracic  vertebra..  The  lesser 
curvature  runs  along  the  left  of  the  spinal  column,  and  crosses  to  the 


I02 


LOCATION,    SIZE,    AND    CAPACITY    OF    THE    STOMACH. 


right  at  the  level  of  the  first  lumbar  vertebra.  The  lesser  curvature 
is  entirely  covered  by  the  liver,  and  can  be  percussed  or  palpated 
only  when  it  is  located  lower  than  normal.  The  pylorus  is  covered 
by  the  right  lobe  of  the  liver,  about  three  to  four  cm.  from  the  median 
line;  it  is  seven  cm.  lower  than  the  cardia.  The  pars  pylorica  (an- 
trum pylori)  extends  further  to  the  right  than  the  pylorus  itself. 
The  greater  curvature  in  its  upper  part  is  largely  covered  by  the 


Fig.  8.— Location  of  the  Stomach— Dorsal  View. 
I.  Left  kidney.     2.  Right  kidney.     3.  Spleen.     4.  Lungs.     5.  Descending  colon.     6.  Ascending 
colon.     7.  Complementary  space  occupied  by  expanding;  lungs  in  inspiration.     S.  Hepatic 
flexure.    9.  Splenic  flexure  of  colon.     The  stomach  occupies  the  space  colored  in  red. 


lung;  its  lower  and  anterior  part  is  in  apposition  with  the  left  h3'po- 
chondrium  and  epigastrium.  When  the  stomach  is  full,  the  greater 
curvature  is  two  to  four  cm.  above  the  umbilicus.  To  the  right  of 
the  median  line  it  ascends  along  the  median  edge  of  the  gall-bladder, 
and  is  continued  into  the  pyloric  part. 

Distention  very  much  facilitates  percussion  and  palpation  of  the 
stomach. 


LIMITS   OB'   GASTRIC   DISTENTION. 


103 


The  conviction  has  been  forced  upon  us  that  the  degree  to  which 
the  stomach  can  be  distended  is  a  very  limited  one.  This  state- 
ment is  made  after  many  hundred  distentions  with  the  intragastric 
stomach-shaped  bag  in  connection  with  a  manometer.  Most  stom- 
achs that  are  in  a  normal  state  will  refuse  to  be  distended  more  than 
100  c.c.  beyond  their  natural  capacity.  Only  in  pathological  thin- 
ning of  the  gastric  walls  and  in  atrophy  of  the  muscularis  is  an  over- 


FiG.  9.— Location  of  the  Stomach — Anterior  View. 
I.  The  stomach.     2.  Liver.     3.  Heart.     4.  Lungs.     5.  Complemental   pleural  spaces.    6.  Trans- 
verse colon. 


distention  conceivable;  even  then  some  of  the  gases  will  escape  by 
the  cardia  before  painful  distention  will  ensue. 

For  these  reasons  distention  with  air  or  carbon  dioxid  is  an  ex- 
pedient and  safe  way  of  determining  the  form  and  location  of  the 
stomach,  and  its  relation  to  any  tumors  that  may  be  present.  There 
is  no  better  way  of  differentiating  gastric  dilatation  from  gastroptosis 
(falling)  than  by  this  process  of  distention. 

This  method  is  carried  out  by  introducing  a  stomach-tube,  to 
the  upper  end  of  which  is  attached  a  double-bulb  pump  arrange- 


I04  LOCATION,    SIZE,    AND    CAPACITY   OF    THE   STOMACH. 

ment  such  as  is  used  in  some  spra}^  apparatus  (Runeberg,  ' '  Deutsch. 
Archiv  f.  klin.  Med.,"  Bd.  xxxiv).  Bouveret  ("Traite  des  Maladies 
de  rEstomac,"  Paris,  1893)  recommends  that  the  air  be  forced  into 
the  stomach  by  blowing  with  the  mouth  through  the  tube.  Riegel 
and  Boas  are  very  fond  of  gastric  distention  by  carbon  dioxid  gas. 
A  teaspoonful  of  bicarbonate  of  sodium,  and  about  the  same  amount, 
or  perhaps  a  little  less,  of  tartaric  acid,  are  dissolved,  each  in  a  sepa- 
rate glass  containing  200  c.c.  of  water. 

First,  the  solution  of  tartaric  acid  is  administered,  and  immedi- 
ately afterward  the  sodium  bicarbonate.  The  patient  must  be  in 
the  dorsal  position,  with  knees  flexed.  Within  the  stomach  a  brisk 
evolution  of  CO2  occurs,  at  once  distending  the  organ  so  that  it  stands 
out  prominently,  and  is  evident  as  a  sharply  defined,  arched  eleva- 
tion. The  greater  curvature  becomes  very  apparent ;  not  so  the 
lesser  one.     The  patient  should  be  told  not  to  belch. 

The  stomach  under  distention  can  be  readily  palpated  or  per- 
cussed. If  tumors  were  made  out  before,  it  is  important  to  deter- 
mine their  seat  after  the  distention.  It  is  possible  thereby  in  many 
cases  to  demonstrate  the  connection  or  non-connection  of  the  tumor 
with  the  stomach  after  distention. 

Accordingly,  tumors  which,  when  the  stomach  was  empty,  were 
palpated  in  the  line  of  the  umbilicus  and  to  the  right,  for  which 
reason  it  might  be  doubted  whether  they  belonged  to  the  stomach, 
after  distention  may  move  upward  to  the  right,  and  toward  the 
anterior  arch  of  the  short  ribs.  One  may  see  and  feel  the  direct 
transition  of  the  tumor  mass  into  the  substance  of  the  stomach,  or 
trace  its  extent  toward  the  pylorus,  or  ascertain  that  it  is  entirely 
independent  of  the  stomach. 

Even  the  disappearance  or  the  becoming  less  distinct  of  a  tumor 
is  very  important,  if  it  occurs  after  distention.  This  is  observed  in 
tumors  of  the  posterior  wall.  If  it  is  easily  movable,  very  close  and 
tight  adhesions  may  be  excluded ;  if  it  is  absolutely  immovable,  it  is 
abnormally  attached  or  fixed.  It  is  evident  that  distention  of  the 
stomach  with  air  or  gas  not  only  enables  one  to  get  a  better  per- 
cussion area,  but  it  serves  another  purpose :  that  of  facilitating  the 
palpation  of  tumors. 

Percussion  and  auscultation  over  the  stomach  frequently  give 
valuable  information  concerning  its  boundaries  without  the  use  of 
instruments.  So  does  the  elucidation  of  "clapotement,"  or  splash- 
ing sounds.     But  when  the  stomach  is  not  distended  or  no  instru- 


PERCUSSION   LIMITS    OF    STOMACH. 


105 


ment  is  used,  differentiation  of  colon  from  stomach  becomes  difficult, 
especially  if  the  abdominal  walls  have  any  moderate  thickness. 
Often  mere  inspection  will  disclose  the  location  of  the  stomach 
when  distended  by  its  own  gases.  In  his  book  on  "Diseases  of 
the  Stomach,"  Riegel  gives,  in  addition  to  the  above,  ten  other 
methods  for  determining  location,  size,  and  capacity,  most  of 
which,  being  more  or  less  fallacious,  we  must  refer  those  specially 


'^ 


Fig.  10. — Normal  Percussion  Limits  of  the  Adult  Stomach. — {Eichhorst.) 
I.  Pronounced  liver  dullness.     2.  Lesser  liver  dullness.     3.  Smaller  heart  dullness.    4.  Larger 
heart  dullness.     5.  Limits  of  stomach  percussion.     6.  Traube's   semilunar  space.     7.  Left 
edge  of  short  ribs. 


interested  in  this  matter  to  Riegel's  book,  pages  41-56.  In  our 
opinion,  all  these  latter  methods  will,  before  many  years,  have  onl}^ 
a  historical  value.  There  is  one  method  for  accomplishing  the  above 
objects,  however,  which  we  can  recommend  from  a  very  large  ex- 
perience, and  which  is  used  extensively  at  our  clinic,  and  of  the 
accuracy  of  which  we  have  had  many  opportunities  to  be  convinced. 
With  our  stomach-shaped  intragastric  rubber  bag  (see  plate  iv) 
and  the  pressure  bottles  A  and  B,  the  location  and  capacity  can 
8 


Io6  LOCATION,    SIZE,    AND   CAPACITY   Ol?   THE   STOMACH. 

be  determined  with  great  ease.  The  rubber  bag  used  for  this  pur- 
pose has  no  sheath  or  guide  for  the  duodenal  tube.  The  stomach 
is  distended  by  blowing  up  the  bag  within  it;  the  amount  of  air 
necessary  thereto  is  measured  afterward  by  allowing  it  to  escape 
into  a  spirometer.  A  less  accurate,  though  quite  practical  method, 
is  to  catch  the  escaping  air  in  a  glass  cylinder  filled  with  water  and 
inverted  over  a  basin. 

It  might  be  claimed  that  our  method  is  a  combination  of  von 
Kelling's,  Schreiber's,  and  Jaworski's  methods,  and  it  does  indeed 
partake  of  part  of  the  devices  of  all  these.  (See  Riegel,  pp.  51,  52, 
and  54.)  Schreiber  used  a  small,  round, — not  a  stomach-shaped, 
— distensible  balloon,  but  no  pressure  bottles  nor  spirometer.  Jawor- 
ski  used  two  pressure  bottles,  but  no  balloon  or  intragastric  bag, 
and  no  spirometer,  while  von  Kelling  used  simply  the  spirometer  to 
measure  the  air,  which  he  forced  into  the  stomach  with  a  double 
bulb,  as  is  used  on  sprays. 

Our  method  of  arriving  at  the  capacity  of  the  stomach  is  really, 
then,  not  entirely  original,  as  it  combines  the  best  of  the  three  older 
methods,  but  it  is  most  convenient  and  reliable.  The  bag,  as  has 
been  shown,  can  at  the  same  time  be  used  for  determining  the  nature 
of  the  motor  function.  It  can  be  asserted,  from  observations  on  a 
large  number  of  patients,  that  there  is  no  other  single  method  which 
is  so  useful,  combining  instruction  concerning  size,  location,  and 
capacity  of  the  stomach  with  that  concerning  its  motor  function. 

The  method  is  as  easy  in  its  application  as  any  which  Riegel 
describes.  The  capacity  can,  for  practical  purposes,  be  read  off  on 
bottle  B,  from  the  amount  of  air  that  has  been  displaced  into  the 
intragastric  bag.  The  cost  of  the  bag  is  one  dollar,  and  a  good  idea 
of  the  motor  function  can  be  had  from  a  water  manometer  in  con- 
nection with  it  after  distention;  with  one  hand  on  the  epigastric 
region,  the  respiratory  movements  can  be  felt,  and  thus  distinguished 
from  the  active  movements  as  expressed  by  the  rise  and  fall  of 
the  water  column  in  the  manometer.  It  may  thus  be  used  with- 
out the  kymograph.*     I^angerhans  ("Archiv  fiir  Verdauungskrank- 

*In  the  shops  of  Baltimore  small  toy  balloons  are  sold  which  are  made  of  very  thin 
but  quite  tough  rubber,  which  my  assistants  have  frequently  used  for  intragastric  disten- 
tion. These  balloons  accompany  a  game  called  "pillow  dex,"  and  are  sold  six  for 
twenty-five  cents.  For  studying  the  motor  function  they  answer  as  well  as  the  more  ex- 
pensive stomach-shaped  bags,  as  I  have  assured  myself  that  on  distention  they  fill  every 
inch  of  space  in  a  dog's  stomach.  For  determining  the  capacity,  however,  the  stomach- 
shaped  bag  is  more  accurate. 


GASTRODIAPHANY. 


107 


heiten,".  Bd.  iii,  S.  312)  prefers  the  use  of  the  intragastric  rubber 
bag  for  the  recognition  of  gastroptosis. 


GASTRODIAPHANY. 
Gastrodiaphany  of  Einhorn. — In  1889  Dr.  Max  Einhorn  suc- 
ceeded in  transilluminating  the  human  stomach  in  the  dark  by 
means  of  a  small  Edison  lamp  attached  to  a  soft-rubber  tube;  from 
the  lamp  through  this  tube,  insulated  conducting  wires  ran  to  a 
storage  battery.  (See  illustration,  Fig.  11.)  At  some  distance  from 
the  rubber  tube  was  a  current-interrupter.  By  this  apparatus  the 
inventor  claimed  to  be  able  to  ascertain  the  exact  position  and  size 
of  the  stomach,  and  to  recognize  tumors  and  thickenings  of  the  front 
wall  by  their  lack  of  translucency. 


Fig.  II.— The  Electrodiaphane. 


In  1867  Milliot  had  succeeded  in  transilluminating  the  stomachs 
of  animals  by  platinum  wires  contained  in  glass  tubes  and  connected 
with  a  Middeldorph's  apparatus. 

Fleischer,  in  his  text-book  ("Path.  u.  Therap.  der  Magen-  u. 
Darmkrankh.,"  p.  789),  claims  to  have  succeeded,  together  with 
Hiifler,  in  transilluminating  the  human  stomach  before  Einhorn. 
If  this  is  really  so,  Fleischer  did  not  publish  his  investigations,  so 
far  as  we  know,  and  certainly  is  not  entitled  to  name  the  method 
after  himself. 

To  Einhorn  is  due  the  credit  of  developing  the  method  as  an  aid 
to  diagnosis.  The  patient,  in  a  fasting  condition,  drinks  from  two 
glasses  to  a  liter  of  water ;  the  apparatus  is  passed  into  the  stomach 
just  as  the  lavage  tube  is  passed,  and  connected  with  the  storage 


I08  LOCATION,    SIZE,    AND    CAPACITY    OF    THE    STOMACH. 

battery.  The  stomach  transmits  the  electric  hght  through  the 
abdominal  walls,  becoming  visible  as  a  red  zone  at  the  place  which 
corresponds  to  its  location.  The  observation  is  executed  in  a  dark 
room. 

In  case  the  anterior  gastric  wall  is  occupied  by  a  tumor,  the  light 
will  not  be  transmitted  at  that  spot,  but  all  around  it  the  rays  will 
penetrate,  thus  evincing  a  dark,  shaded  area  in  a  luminous  zone. 

We  are  in  the  habit  of  marking  the  ribs,  particularly  the  um- 
bilicus, xiphoid  cartilage,  and  symphysis  pubis,  with  phosphorus, 
so  that  they  can  be  seen  in  the  dark  and  serve  as  landmarks  to  the 
exact  abdominal  area  in  which  the  light  permeates.  In  1891  Dr. 
Howard  A.  Kelly  prompted  us  to  attempt  transillumination  of  the 
colon  by  this  method,  and  the  author  demonstrated  it  to  the  Clinical 
Society  of  Maryland  in  that  year.  Later  Heryng  and  Reichmann 
("Therap.  Monatshefte,"  1892)  published  the  first  account  of  trans- 
illumination of  the  colon.  The  water-circulating  diaphane  devised 
by  these  clinicians,  to  prevent  heating  of  the  lamp,  possesses  no 
advantages  whatsoever  over  Einhorn's  instrument. 

We  have  been  able  to  illuminate,  in  successive  portions,  the  entire 
colon  in  this  manner,  and  demonstrated. prolapse  of  the  colon  thereby. 
As  the  duodenum  is  but  ten  to  twelve  inches  long,  a  diaphane  of 
proportionate  length  has  been  introduced  into  the  ileum  in  our 
clinic.  We  are  not  aware  that  this  extension  of  electrodiaphany  to 
the  small  intestine  has  been  practised  before  we  published  an  original 
device  for  intubating  the  duodenum ;  it  would  be  impossible  without 
such  a  method. 

Notwithstanding  the  conservatism  of  Riegel  and  Fleiner  ("Lehr- 
buch  d.  Krankh.  d.  Verdauungsorgane, "  p.  223)  and  the  objections 
of  Boas  and  Debove  and  Remond,  we  consider  the  method  valuable. 
It  certainly  is  convenient  for  the  rapid  diagnosis  and  the  differentia- 
tion between  gastrectasia  and  gastroptosis. 

For  the  recognition  of  tumors,  a  much  stronger  light  than  that 
used  by  Einhorn — namely,  eight  to  ten  volts — may  be  useful,  and 
one-half  of  the  lamp  coated  by  a  reflecting  mirror  of  mercury,  which 
can,  of  course,  be  controlled  by  turning  the  tube  outside  of  the 
mouth.  At  a  demonstration  which  we  were  requested  to  give 
before  the  Clinical  Society  of  Maryland  (1891),  the  apex  impulse  of 
the  heart  was  visible  in  the  dark  after  transillumination. 

According  to  Einhorn,  the  method  can  be  carried  out  both  in 
the   erect  and   the   reclining  position.     He   advises   to   permit  the 


POSITION    OF    STOMACH    IN    DILATATION.  109 

patient  to  drink  only  one  to  two  glasses  of  water  (200  to  450  c.c.), 
which  amount  will  not  distend  the  stomach  beyond  its  natural 
capacity  and  position.  When  a  stomach  is  distended  with  CO2,  or 
filled  with  water,  it  is  unavoidably  enlarged  somewhat.  Heryng 
and  Reichmann  recommend  examining  the  patient  in  an  erect  posi- 
tion and  with  the  stomach  filled  with  from  one  to  two  liters  of  water. 
In  this  position  and  with  that  quantity  of  water,  the  organ  can  not 
fail  to  be  increased  beyond  its  natural  size  and  moved  out  of  its 
natural  situation.  Kuttner  and  Jacobson  ("Berliner  klin.  Woch- 
enschr.,"  1893,  Nos.  39  and  40)  assert  that  the  transilluminated 
area  projected  on  the  belly-wall  does  not  correspond  to  the  stomach 
alone,  but  also  to  light  that  is  diffused  through  loops  of  intestine 
adjacent  to  the  stomach,  and  filled  only  with  gas.  They  found  that 
the  image  is  covered  up  wherever  the  liver  is  superimposed  upon 
the  stomach,  or  intestinal  loops  filled  with  feces,  or  tumors  of  the 
anterior  wall  intervene  between  the  source  of  the  light  and  the 
abdominal  parietes.  It  is  possible  to  determine  only  the  inferior 
and  left  lateral  limits  of  the  stomach  by  diaphany  when  the  organ 
is  in  its  normal  position,  for  the  lower  edge  of  the  liver  prevents 
the  transillumination  of  the  remaining  parts.  It  is  therefore  not 
possible  to  make  the  diagnosis  of  all  cases  of  dilatation  by  gastro- 
diaphany  alone,  for,  as  we  shall  show,  there  are  dilatations  in  which 
the  stomach  does  not  sink  down  to  any  marked  degree. 

But  in  gastroptosis,  where  the  stomach  has  sunk  down  as  a  whole 
and  is  adjacent  to  the  anterior  abdominal  wall,  gastrodiaphany 
will  give  characteristic  pictures,  and  enable  one  to  determine  both 
the  upper  and  lower  limits.  When  the  stomach  has  sunk  down,  it 
loses  its  surface  contact  with  the  diaphragm,  and  therefore  the 
transilluminated  figure  will  show  no  respiratory  movement. 

In  dilatation  the  stomach  lies  in  the  normal  position,  or  very 
nearly  so,  with  its  upper  portions,  which  can  not  be  transilluminated. 
In  this  condition  the  area  of  light  on  the  belly-wall  will  show  respira- 
tory movements  on  account  of  the  contact  of  the  stomach  with  the 
diaphragm.  Kuttner  and  Jacobson  hold  that  when  the  transillumi- 
nated zone  shows  distinct  respiratory  movement,  the  lesser  curva- 
ture is  in  its  normal  position,  and  if  the  zone  is  below  the  umbilicus, 
— i.  e.,  low  position  of  the  greater  curvature, — these  signs  together 
indicate  a  dilatation,  provided  transillumination  through  the  intes- 
tines can  be  excluded.  The  so-called  vertical  position  of  the  stomach 
may  effect  a  low  situation  of  the  transillumination,  but  not  a  simul- 


no  LOCATION,    SIZE,    AND    CAPACITY   OF    THE    STOMACH. 

taneous  respiratory  movability  of  the  lower  light  zone,  because  in 
this  case  the  lesser  curvature  has  moved  away  from  the  diaphragm. 
It  is  conceivable  that  gastrodiaphany  may  aid  in  the  recognition 
of  tumors  of  the  anterior  wall  at  a  time  when  these  can  not  be  de- 
tected by  other  methods  of  investigation.  In  such  cases  the  trans- 
illumination will  be  impossible  because  of  thickening  of  the  gastric 
walls.  According  to  these  observers  gastrodiaphany  is  a  valuable 
method  for  distinguishing  between  dilatation  and  gastroptosis. 

Meltzing  {loc.  cit.)  made  a  large  number  of  experiments  on  healthy 
individuals  with  the  electrodiaphane,  after  which  he  came  to  the 
conclusion  that  the  empty  stomach  occupies  a  larger  area  in  the  epi- 
gastrium than  could  be  hitherto  evidenced  by  percussion  or  gaseous 
distention.  This  is  due,  he  argues,  to  the  fact  that  percussion  can 
only  give  the  note  from  that  portion  of  the  stomach  which  is  directly 
adjacent  to  the  abdominal  wall.  The  large  curvature,  however,  is 
not  adjacent,  and  therefore  can  not  be  made  out  by  percussion. 
The  same  relative  condition  must  evidently  prevail  when  the  stomach 
is  filled  with  gas  or  water.  This  investigator  found  that  the  greatest 
differences  existed  in  the  respiratory  movability  of  the  transillumi- 
nated  area  according  to  the  position  of  the  patient.  He  holds  that 
it  is  not  due  to  direct  contact  of  the  stomach  with  the  diaphragm, 
and  that  movability  which  is  evident  in  the  reclining  position  may 
disappear  almost  entirely  in  the  erect  position.  He  declares  that 
the  differential  diagnosis  between  dilatation  and  gastroptosis  by  the 
presence  or  absence  of  respiratory  movability  of  the  illuminated 
area  is  not  reliable.  In  a  later  pubhcation  Meltzing  ("Archiv  f. 
Verdauungskrankheiten,"  Bd.  ii,  H.  4)  attempted  to  prove  the 
position  of  the  electric  lamp  within  the  stomach  by  the  use  of  a 
nlagnetic  sound,  and  claims  to  have  found  that  the  results  of  both 
methods  agree  within  the  breadth  of  one  finger.  Kuttner,  Jacobson, 
Renvers,  Langerhans,  Meinert,  and  recently  Kelhng  have  proved 
without  doubt  that  the  method  is  liable  to  give  erroneous  results. 
In  the  first  place,  the  illuminated  area  may  not  belong  to  the  stomach 
exclusively,  and,  secondly,  we  are  not  sure  whether  the  location  of 
the  strongest  intensity  of  the  light  really  corresponds  to  the  location 
of  the  lamp.  These  sources  of  error  may  arise  in  two  ways :  i .  The 
inferior  border  of  the  stomach  may  appear  lower  than  the  lamp 
really  is — a  deception  which  can  be  brought  about  when  the  greater 
curvature  and  the  lamp  lying  in  it  are  pushed  away  from  the  abdom- 
inal wall  by  a  distended  intestinal  loop,  and  the  irradiation  is  spread 


SOURCES    OF    ERROR    IN    GASTRODIAPHANY.  Ill 

around  this  entire  loop  in  a  downward  direction.  AA'hen  the  lamp  is 
allowed  to  wander  along  the  greater  curvature  in  a  stomach  filled 
with  water,  one  may  occasionally  observe,  during  the  transillumina- 
tion, that  a  circular  or  elliptical  very  bright  spot  suddenl}^  appears 
below  the  border-line  of  the  gastric  limit  indicated  by  the  passing 
lamp;  that  this  bright  area  does  not  belong  to  the  stomach  can  be 
demonstrated  by  the  high  tympanitic  tone  which  the  circular  bright 
spot  will  give  on  percussion.  I  have  repeatedly  observed  this  phe- 
nomenon during  transillumination,  and  can  not  explain  it  in  any 
other  way  than  that  the  rays  of  light  from  the  lamp  are  deviated 
anteriorly  through  a  distended  intestinal  loop  superimposed  partially 
on  the  greater  curvature.  I  have  also  made  several  experiments 
on  the  dead  subject  in  the  method  indicated  by  Kelling, — a  number 
of  the  subjects  were  frozen  before  the  experiment  so  that  mova- 
bility  of  the  abdominal  viscera  was  impossible, — and  been  convinced 
that  the  transilluminated  area  was  two  inches  lower  than  the  real 
position  of  the  lamp. 

2.  The  lower  border  of  the  stomach  may  appear  too  high.  This 
may  occur  when  the  lamp  lying  in  the  greater  curvature  is  cut  off 
from  the  abdominal  wall  by  opaque  objects  not  transmitting  light — 
such  as  intestinal  loops  filled  with  feces  or  neoplasm. 

In  order  to  obtain  reliable  results  from  gastrodiaphany,  it  is 
important  that  the  patient's  bowels  should  be  cleared  out  by  enema, 
which  will  evacuate  the  colon,  and  about  twelve  hours  before  the 
enema  is  given  a  saline  purge  or  a  dose  of  castor  oil  will  remove 
fecal  accumulations  from  the  small  intestine.  The  bladder  must 
be  emptied  before  the  examination,  for  when  the  stomach  is  very 
low,  it  has  in  some  of  my  cases  been  superimposed  upon  the  bladder, 
and  the  latter  was  found  to  be  capable  of  being  transilluminated  by 
the  light  in  the  fallen  stomach.  This  precaution  is  especially  neces- 
sary when  it  is  desired  to  illuminate  the  small  intestine. 

We  have  experimented  with  incandescent  lamps  requiring  a 
current  of  from  eight  to  ten  volts.  This  intensity  of  light,  while 
it  is  of  advantage  when  it  is  desirable  to  determine  the  topographical 
limits  of  palpable  tumors,  is  a  disadvantage  when  we  wish  to  simply 
transillumine  the  gastric  wall  that  is  free  from  neoplasm.  The 
stronger  the  lamp  is,  the  more  deceptive  will  be  the  irradiation  through 
adjacent  loops  of  the  intestine  and  colon.  The  most  important 
literature  of  the  subject  is  presented  by  Oppler,  volume  iii  of  the 
"Archiv   fiir   Verdauungskrankheiten, "    page    334,     The    following 


112  IvOCATlON,    SIZE,    AND    CAPACITY   OF    THE    STOMACH. 

guiding  maxims  may  be  deducted  from  the  literature,  which  I  have 
subjected  to  a  critical  review  to  determine  the  actual  value  of  the 
method;  these  rules  I  know  from  personal  experience  are  important 
to  the  practitioner  in  using  this  method:  (i)  The  stomach  of  the 
patient  must  be  empty  and  all  remnants  of  food  and  gas  must  be 
evacuated  as  far  as  possible.  (2)  The  intestine  must  also  be  evacu- 
ated of  its  contents  and  of  gas  by  a  purge  and  by  enema.  (3)  The 
bladder  must  be  evacuated.  (4)  The  transillumination  must  be  con- 
ducted in  a  completely  dark  room.  (5)  For  determining  the  size 
and  location  of  the  stomach,  a  lamp  of  five  candle-power  should  be 
used.  For  determining  the  limits  of  palpable  tumors,  a  lamp  of 
eight  normal  candle-power  is  advisable.  (6)  The  diaphany  should 
be  conducted  in  the  erect  as  well  as  in  the  reclining  position.  (7) 
In  the  reclining  position  the  lamp  gravitates  away  from  the  anterior 
gastric  wall,  and  frequently  no  light  effect  is  at  all  observable.  Even 
in  the  erect  position,  when  the  empty  stomach  is  transilluminated, 
no  complete  light  image  of  the  stomach  can  be  observed  on  the 
abdominal  wall,  but  only  certain  undefined  areas  of  light  resembhng 
spots  or  discs.  (8)  The  results  of  diaphany  correspond  more  and 
more  closely  to  the  real  condition,  the  thinner  and  freer  from  fat 
the  abdominal  walls  are.  In  cases  where  the  walls  are  thin,  the 
limits  agree  well  with  the  actual  limits  of  the  stomach,  but,  as  a 
general  thing,  those  obtained  by  diaphany  are  somewhat  lower  than 
the  actual  limit  of  the  stomach.  (9)  If  the  lamp  is  allowed  to  glide 
along  the  greater  curvature  of  the  empty  stomach  by  drawing  out  the 
tube,  a  series  of  light  spots  will  be  observed,  which  will  indicate  ap- 
proximately the  position  of  the  greater  curvature,  provided  a  lamp 
has  been  used  not  exceeding  four  to  five  candle-powers,  and  only  the 
bright  center  of  the  light  discs  are  taken  into  consideration.  (10) 
Excessive  development  of  fat  in  the  subcutaneous  tissue  and  omen- 
tum and  strongly  developed  abdominal  walls  render  the  results  of 
the  illumination  fallacious.  This  also  occurs  when  a  stronger  lamp 
has  been  introduced,  because  in  that  case  the  more  illuminated 
center  of  the  light  discs  can  not  be  recognized,  and  the  adjacent 
organs  will  also  refract  the  light.  (11)  Megalogastria,  which  has 
been  observed  in  individuals  with  thick  abdominal  walls,  seems  to 
be  due  to  this  deception.  But  even  deducting  any  possible  irradia- 
tion of  light  beyond  the  limits  of  the  organ,  it  is  certain  that  the 
greater  curvature  of  the  empty  stomach  is  at  a  lower  level  than  has 
hitherto  been  assumed.     This  is  not  invariably  the  case,  however, 


CRITICISM    AND    LIMITATION    OF    ELECTMODIAPHANY.  II3 

and  from  our  own  critical  observations,  conducted  on  a  sufficiently- 
large   material,   we   consider  such  extreme  variations   as   Meltzing 
described  (loc.  cit.)  as  exceptional.      (12)  When  the  stomach  is  filled 
with  from  500  to  1500  c.c.  of  water,  a  continuous  picture  is  obtained 
in  form  of  a  luminous  disc.      (13)  By  this  method  the  lower  edges 
of  the  right  and  left  lobes  of  the  liver  and  the  anterior  margin  of  the 
spleen  can  be  accurately  determined.     The  former  shuts  off  the  light 
at  the  right  superior  boundary,  and  the  spleen  at  the  left  superior 
boundary  of  the  luminous  area.     (14)  When  the  stomach  is  thus 
filled,  the  position  of  the  greater  curvature  is  somewhat  lower  than 
in  the  empty  stomach,  and  it  is  from  four  to  ten  centimeters  lower 
in  the  erect  than  in  the  reclining  position.     Meltzing  and  Martins 
assert  that  a  line  connecting  the  anterior  superior  spines  of  the 
ilium  is  exceeded  in  the  majority  of  cases.     If  a  lamp  of  only  four 
candle-powers  has  been  used,  we  should  consider  a  stomach  illumi- 
nated beyond  this  line  as  dilated  or  prolapsed  beyond  a  doubt. 
Much  depends  in  these  cases  upon  the  strength  of  the  light  and  the 
amount  of  water  introduced  into  the  stomach.     (15)   Concerning 
the  respiratory  movements  of  the  illuminated  figure,  I  should  say 
that  in  my  experience  it  moves  downward  distinctly  during  inspira- 
tion when  the  body  is  in  the  reclining  position,  but  in  the  upright 
position  the  movements  are  very  shght,  and  in  case  there  is  gastrop- 
tosis,  there  are  no  respiratory  movements  whatever.     In  the  rare 
cases  of  extreme  dislocation  of  the  stomach,  we  could  observe  no 
respiratory  movement  even  in  the  reclining  position.      (16)  Filhng 
the  stomach  with  1500  c.c.  of  water  lowers  the  greater  curvature 
somewhat.     If  only  300  or  400  c.c.  are  introduced,  the  lower  margin 
of  the  stomach  may  even  rise  a  httle  higher  than  the  line  it  occupied 
when  empty.     Full  distention  with  water  enlarges  the  transillumi- 
nated  area  toward  the  right  of  the  median  line. 

The  method  of  electrodiaphany  has  been  extolled  by  a  number 
of  investigators,  and  severely  criticized  by  others.  In  the  existing 
chaotic  condition  of  the  various  opinions,  and  as  the  facilities  for 
obtaining  the  electric  current  in  physicians'  offices  in  the  cities  are 
becoming  greater  with  every  day,  insuring  a  more  frequent  and 
extensive  appHcation  of  this  method,  the  author  considers  it  his 
duty  to  sift  the  opinions  presented,  and  subject  them  to  critical 
analysis,  along  the  guiding  lines  of  a  large  experience.  No  matter 
how  classical  or  well  established  the  authority  that  presents  an 
opinion,  a  writer  with  an  analytical  mind  will  see  the  utility  and 


114  LIT^ATURE    ON   GASTRODIAPHANY. 

results  of  any  method  through  the  spectacles  of  his  individual  ex- 
perience. 

From  that  standpoint  I  feel  justified  in  emphasizing  the  fact  that 
electrodiaphany  will  give  rise  to  serious  deceptions  unless  supple- 
mented by  other  well-established  methods,  and  that  the  diagnosis 
should  never  be  based  upon  transillumination  alone.  Electro- 
diaphany can  be  satisfactorily  replaced  by  other  methods  of  exam- 
ination. With  these  limitations,  we  believe  the  method  to  be  a 
valuable  diagnostic  aid,  serviceable  for  the  determination  of  the 
normal  and  abnormal  topography  of  the  abdominal  organs. 

The  abnormal  shape  and  situation  of  the  stomach,  so-called  loop 
form  and  vertical  position,  may  be  easily  recognized  in  many  cases. 
In  very  rare  cases  diaphany  may  suggest  the  presence  of  a  tumor  that 
is  not  demonstrable  by  any  other  method. 

It  may  be  possible  to  detect  tumors  on  the  lower  edge  of  the  liver 
thereby,  and  possibly  enlargement,  tumor,  and  dislocation  of  the 
spleen.  It  does  not  present  a  useful  means  to  determine  disturb- 
ances of  the  peristaltic  functions  or  gastric  atony.  When  a  small 
quantity  of  water  is  introduced  into  a  healthy  stomach,  the  lower 
curvature  should  rise  somewhat  higher.  If  this  does  not  take  place, 
we  might  suspect  gastric  atony.  If  the  transilluminated  figure  does 
not  alter  its  size  on  introducing  a  small  and  then  a  large  amount  of 
water,  this  would  be  suggestive  of  motor  insufTiciency.  When  the 
luminous  area  shows  up  very  low  upon  the  abdomen,  great  caution 
is  required  to  differentiate  between  (i)  physiological  megalogastria, 
(2)  dilatation,  (3)  gastroptosis.  The  respiratory  movabilities  which 
we  have  already  described  do  not  sulhce  to  make  a  differential 
diagnosis,  for  in  megalogastria  (normal  large  stomach),  as  well  as  in 
dilatation,  the  respiratory  movability  is  often  very  slight  in  the  erect 
position,  and  in  gastroptosis  there  may  be  sHght  respiratory  move- 
ment in  the  reclining  position.  Only  in  total  gastroptosis  do  we 
find  the  respiratory  movement  entirely  absent. 

These  evidences  suffice  to  show  that  electrodiaphany  is  useful 
only  in  association  with  other  methods  of  clinical  diagnosis. 

LITERATURE 

ON   GASTRODIAPHANY. 

1,  Boas,  "  Ueber  die  Bestimmung  der  Lage  und  Grenzen  des  Magens  durch 
Sondenpalpation,"  "  Centralbl.  f.  innere  Medicin,"  1896,  No.  6. 

2.  Boas,  "  Diagnostik  und  Therapie  der  Magenkrankheiten,"  1895,  Theil  11, 
p.  148. 


LITERATURE    ON    GASTRODIAPHANY.  II5 

3.  Boas,  "  Ueber  den  heutigen  Stand  unserer  Kenntnisse  von  Pathol,  u. 
Therap.  der  Motilitatsstorungen  des  Magens,"  "Therap.  Monatsh.,"  1896, 
Heft  I,  II. 

4.  Briiggemann,  "  Ueber  den  Tiefstand  des  Magens  bei  Chlorose."  Inaug.- 
Diss.,  Bonn,  1895. 

5.  Einhorn,  "  New-Yorker  medicin.  Monatsschrift,"  November,  1889. 

6.  Einhorn,  "  Berliner  klinische  Wochenschrift,"  1892,  No.  51. 

7.  Epstein,  "  Die  Anwendung  der  Gastrodiaphanie  beim  Saugling,"  "  Jahr- 
buch  f.  Kinderheilkunde,"  N.  F.  xli.  Heft  iii,  iv. 

8.  Hirschler,  "Ueber  Gastrodiaphanie";  referirt  nach  "Wien.  klinische 
Wochenschr.,"  1894,  No.  31. 

9.  Heryng  und  Reichmann,  "  Ueber  elektrische  Magen-  und  Darmdurch- 
leuchtung,"  "Therap.  Monatsh.,"  Marz,  1892. 

10.  Kelling,  "  Archiv  fiir  Verdauungskrankheiten,"  Band  11,  1896. 

11.  Kelling,  "  Physikalische  Untersuchungen  iiber  die  Druckverhaltnisse  in 
der  Bauchhohle,  sowie  iiber  die  Verlagerung  und  die  Vitalcapacitat  des 
Magens,"  "  Volkmann'sche  Vortrage,"  N.  F.  cxLiv. 

12.  Kelling,  "  Ueber  die  Fehlerquellen  der  Magendurchleuchtung,"  "  Archiv 
fiir  Verdauungskrankheiten,"  Band  iii.  Heft  i. 

13.  Kuttner,  "  Einige  Bemerkungen  zur  elektrischen  Durchleuchtung  des 
Magens,"  "  Berliner  klinische  Wochenschr.,"  1895,  No.  37. 

14.  Kuttner,  "  Zur  Durchleuchtung  des  Magens,"  ebenda,  1896,  No.  38. 

15.  Kuttner  und  Dyer,  "Ueber  Gastroptose,"  "Berliner  klinische  Wochen- 
schr.," 1897,  No.  20. 

16.  Kuttner  und  Jacobson,  "  Ueber  die  elektrische  Durchleuchtung  des 
Magens  und  deren  diagnostische  Verwertbarkeit,"  "Berliner  klinische  Woch- 
enschr.," 1893,  No.  39. 

17.  Langerhans,  "  Magendurchleuchtung  und  Magenaufblahung,"  "  Wiener 
medicinische  Blatter,"  1895,  No.  45. 

18.  Leo,  "Ueber  Gastroptose  und  Chlorose,"  "Deutsche  med.  Wochen- 
schr.," ,1896,  No.  12. 

19.  Martins,  "  Naturforscherversammlung,"  Wien,  1894;  referirt  nach 
"  Wiener  med.  Presse,"  1894,  No.  40. 

20.  Martius,  "  Ueber  die  wissenschaftliche  Verwertbarkeit  der  Magensdurch- 
leuchtung,"  "Centralbl.  f.  innere  Medicin,"  1895,  No.  49. 

21.  Meinert,  "  Zur  Frage  von  der  diagnostischen  Verwertbarkeit  der  Magens- 
durchleuchtung,"  "  Centralbl,  f.  innere  Medicin,"  1895,  No.  44. 

22.  Meinert,'  "  Ueber  normale  und  pathologische  Lage  des  menschlichen 
Magens  and  ihren  Nachweis,"  ebenda,  1896,  Nos.  12,  13. 

23.  Meinert,  "  Zur  Aetiologie  der  Chlorose,"  Bergmann,  Wiesbaden,  1895. 

24.  Meinert,  "  Ueber  einen  bei  gewohnlicher  Chlorose  des  Entwickelungs- 
alters  anscheinend  constanten  pathologisch-anatomischen  Befund,  und  iiber 
die  klinische  Bedeutung  Desselben,"  "  Volkmann'sche  Sammlung,"  N.  F., 
1895,  115,  116. 

25.  Meltzing,  "  Magendurchleuchtungen,"  "  Zeitschrift  f.  klinische  Medi- 
cin," Band  xxvii.  Heft  11,  ff. 

26.  Meltzing,  "  Die  Controle  der  Magendurchleuchtung  mittels  der  Magnet- 
sonde,"  "Archiv  f.  Verdauungskrankheiten,"  Band  11,  Heft  iv. 

27.  Meltzing,  "  Gastroptose  und  Chlorose,"  "  Wiener  medicin.  Presse,"  1895, 
Nos.  30-34. 


Il6         STOMACH-TUBE   AND   TECHNICS    OF   ITS   INTRODUCTION. 

28.  Mikulicz,  "  Wiener  medicin.  Presse,"  1881,  No.  45  fif.,  und  "  Wiener  med. 
Wochenschr.,"  1883,  Nos.  23,  24. 

29.  Milliot,  "  Internationaler  medicin.  Congress  zu  Paris";  citirt  nach 
"  Schmidt's  Jahrbiichern,"  Band  cxxxvi,  S.  143. 

30.  Pariser,  "  Berliner  medicinische  Gesellschaft,"  6.  Juli,  1892. 

31.  Reichmann,  "  Ueber  die  elektrische  Durchleuchtung  des  Magens  fur 
diagnostische  Zwecke,"  "  Gazeta  lekarska,"  1896,  No.  32. 

32.  Renvers,  "Verein  fiir  innere  Medicin,"  4,  iv,  1892. 

33.  Rosenheim,  "Berliner  klinische  Wochenschr.,"  1896,  No.  13. 

34.  Schwartz,  "  Ueber  den  diagnostischen  Werth  der  elektrischen  Durch- 
leuchtung menschlicher  Kbrperhohlen,"  "  Beitrage  zur  klinische  Chirurgie," 
Band  xxiv,  Heft  iii. 

35.  Van  der  Weijde,  "  De  Doorschijnung  van  de  Maag,"  "  Nederl.  Tijdschr. 
voor  Geneeskunde,"  1895,  Deel  11,  No.  12. 


CHAPTER  XI I. 

THE  STOMACH-TUBE  AND  TECHNICS  OF  ITS 
INTRODUCTION. 

Examination  of  Stomach  Contents. — Test-meals:  Their  Effect  upon  the 
Amount  of  Acid  Secreted. — Literature. 

No  other  kind  but  a  soft  elastic  stomach-tube  should  be  used,  and 
before  introducing  it  for  the  first  time  in  any  patient,  we  should 
always  carefully  instruct  him  or  her  regarding  the  object  and  utility 
of  the  procedure  and  its  harmlessness.  Whenever  we  can  do  so,  we 
give  very  timid  patients  an  opportunity  of  observing  with  what 
ease  more  experienced  patients  introduce  the  tube  on  themselves. 
This  has  a  most  comforting  effect.  Weak  and  old  persons  should 
always  be  treated  on  the  bed,  several  thick  towels  being  placed  on 
the  patient's  chest  and  beneath  the  chin ;  if  the  case  is  to  be  examined 
in  an  erect  position,  linen  gowns  are  drawn  over  the  breast  and  lap, 
or  an  additional  rubber  sheet  to  protect  the  clothing.  Dr.  Fenton 
B.  Turck,  of  Chicago,  has  devised  a  useful  rubber  pocket,  which  is 
suspended  under  the  chin  during  lavage,  and  protects  the  garments 
of  the  patients  from  the  mouth  discharges.  If  the  throat  and  fauces 
are  very  tender  (often  found  in  excessive  smokers),  it  is  advisable 
to  precede  the  introduction  of  the  tube  by  spraying  the  throat  with 


HOW  TO  introduce;  a  stomach-tube.  I  I  7 

a  three  per  cent,  solution  of  cocain  hydrochlorate  or  the  following 
anodyne  spray: 

K: .     Three  per  cent,  solution  of  cocain  hydrochlorate  in 

benzoinol, 2  fluidounces 

One  per  cent,  solution  of  menthol  in  liquid  vaselin 

oil, ^  of  a  fluidounce. 

Use  in  atomizer  for  spraying  the  throat.  Mix. 

Every  patient  should  possess  his  or  her  own  tube,  especially  in 
private  practice.  In  hospital  practice  a  special  tube  should  invariably 
be  obtained  for  every  carcinomatous,  syphilitic,  and  tuberculous 
patient,  and  its  use  limited  to  that  particular  person.  After  the 
tube  has  been  used  it  should  be  carefully  washed,  first  with  soap  and 
warm  water,  rinsed  out  by  a  current  of  warm  water  and  disinfected 
by  placing  it  in  a  six  per  cent,  solution  of  carbolic  acid  or  a  saturated 
solution  of  boric  acid  or  thymol,  in  which  the  instrument  should  be 
kept  coiled  until  it  is  used  again.  Much  has  been  written  about  the 
construction  of  the  lower  end  of  the  tube.  The  author's  experience 
is  that  the  Ewald  tube  as  pictured  on  page  126  answers  every  pur- 
pose. The  lower  end  of  the  tube  should  be  open,  as  there  can  be  no 
doubt  that  this  facilitates  the  entrance  of  chyme  into  the  tube  when 
the  contents  are  drawn,  and  also  the  entrance  and  exit  of  water  during 
lavage.  Two  larger  lateral  openings  at  opposite  sides  of  the  tube 
and  about  two  inches  apart,  are  advantageous  for  the  same  object. 

The  Ewald  tube  possesses  also  six  to  eight  smaller  openings, 
which  may  not  favor  the  aspiration  of  thick  chyme,  yet  are  valuable 
for  lavage,  when  it  is  desirable  to  produce  a  mechanical  effect  on 
the  mucosa  by  having  many  fine  streams  fall  upon  it.  They  have 
the  disadvantage  of  rendering  the  tube  more  difficult  to  clean.  When 
there  is  reason  to  suppose  a  gastric  or  esophageal  ulcer,  neoplasm, 
or  stenosis,  I  prefer  a  tube  that  is  closed  at  the  lower  end,  because 
this  form  is  more  likely  to  pass  over  these  structural  abnormalities 
without  injuring  them.  If  the  patient  is  quiet  and  composed,  it  is 
safe  to  let  him  introduce  the  tube  himself  even  at  the  first  oppor- 
tunity, the  main  points  to  impress  upon  him  being  three:  (i)  To 
swallow  several  times  when  the  tube  has  reached  the  root  of  the 
tongue;  (2)  to  breathe  deeply  and  regularly;  (3)  to  push  the  tube 
with  both  hands  as  soon  as  it  has  turned  downward  into  the  esoph- 
agus. Introducing  the  finger  into  the  mouth  to  depress  the  tongue 
is  rarely  necessary.  Involuntary  or  intentional  coughing  must  be 
suppressed  by  exercise  of  self-control,  as  it  will  inevitably  prevent 


Il8         STOMACH-TUBE    AND   TECHNICS    OE   ITS    INTRODUCTION. 

the  point  of  the  tube  from  entering  the  esophagus  and  turn  it  back 
into  the  mouth.  The  more  passive  and  quiet  a  patient,  the  easier 
can  the  procedure  be  carried  out. 

In  addition  to  the  execution  of  lavage  the  stomach-tube  is  useful 
for  the  following  diagnostic  purposes:  (i)  To  draw  the  contents  of 
the  stomach  for  chemical  and  microscopical  analysis;  (2)  to  estab- 
lish the  permeability  of  the  esophagus;  (3)  to  determine  the  lower 
border  of  the  stomach  by  palpating  the  tube  through  the  abdominal 
walls.  This  method  was  originally  proposed  by  Leube,  but  has 
been  deserted  even  by  him  on  account  of  its  inaccuracy.  In  many 
cases  it  is  not  possible  to  palpate  a  tube  through  the  abdominal 
walls,  and  even  where  palpable,  it  is  not  possible  to  differentiate  a 
dilatation  from  a  descent  or  ptosis. 

It  is  very  important  to  use  graduated  wide-mouthed,  transparent 
glass  bottles  of  about  one  quart  (one  liter)  capacity  for  lavage.  At 
least  two  such  bottles  are  needed — one  to  pour  the  water  into  the 
funnel,  the  other  to  catch  the  outflow.  This  outflow  should  always 
be  measured,  and  efforts  to  regain  the  entire  quantity  that  has 
entered  the  stomach  must  be  made  before  an  additional  supply  is 
poured  in.  Neglect  of  this  precaution  may  produce  dangerous  over- 
distention  of  the  organ. 

It  is  not  necessary  to  lubricate  the  stomach-tube  with  any  oil  or 
vaselin — there  is  generally  mucus  enough  in  the  esophagus  to  facili- 
tate the  passage.     It  is  sufficient  to  moisten  it  with  water. 

In  the  "  New  York  Medical  Journal"  for  December  28,  1895,  volume  LXll, 
No.  26,  page  822,  a  new  double-current  stomach-tube  has  been  described  by 
the  author,  through  which  the  inflow  and  outflow  goes  on  uninterruptedly  at 
the  same  time.  This  tube  is  recommended  only  as  a  time-saver  for  the  spe- 
cialist in  practice ;  the  simple  tube  will  fulfil  every  requirement ;  it  is  the  safest 
instrument,  even  though  in  lavage  of  progressed  gastrectasia  it  may  require 
much  more  time. 

From  20  measurements  of  female  patients,  the  author  has  found  that  the 
average  distance  from  the  incisor  teeth  to  the  deepest  portion  of  the  stomach 
is  55  cm.,  and  in  36  measurements  of  healthy  males  the  same  distance  was 
found  to  be  60  cm.  In  cadavers  this  distance  is  in  both  sexes  shortened  by 
postmortem  rigor,  according  to  the  author's  experience,  it  having  been  found 
to  be  52.5  cm.  on  the  average  for  females  in  12  different  subjects.  In  12  male 
cadavers,  the  average  distance  from  the  incisor  teeth  to  the  deepest  part  of  the 
stomach  was  54  cm. 

In  ten  cases  of  dilatation  of  the  stomach,  the  average  distance  from  the  in- 
cisor teeth  to  the  deepest  portion  of  the  stomach,  as  measured  by  as  rigid  a 
sound  as  could  safely  be  introduced,  was  69  cm. 

The  author,  on  visiting  Professor  F.  Penzoldt,  in  Erlangen,  in  July,  1895,  was 


TECHNICS    OF    INTRODUCING    STOMACH-TUBE. 


119 


surprised  to  find  this  pioneer  of  digestive  pathology  still  advocating  the  use  of  a 
guide  in  the  shape  of  a  flexible  stick  or  whalebone,  which,  during  introduction, 
is  inserted  into  the  gastric  tube  to  facilitate  its  entering  the  esophagus  after  it 
curves  over  the  base  of  the  tongue. 

In  his  most  recent  contribution  to  the  subject,  Penzoldt  {loc.  cit.,  27)  gives 
minute  details  as  regards  the  method  of  application  of  the  Leitungsstab  or  Matt- 
drin  within  the  tube,  and  says  that  it  should  be  oiled  to  facilitate  its  removal 
when  the  tube  has  reached  the  middle  of  the  esophagus.  He  also  suggests 
catching  the  tip  of  the  lavage  tube  between  the  index  and  middle  fingers  of  the 
left  hand,  which  are  inserted  into  the  patient's  mouth,  and  bending  the  tip  down 
over  the  base  of  the  tongue  until  it  enters  the  esophagus.  This  is  the  method 
advocated  by  his  teacher.  Professor  Leube  {loc.  cit.,  2),  and  also  by  Rosen- 
heim (36). 

In  the  writer's  experience  the  intratubal  whalebone  guide  and  the  insertion 
of  the  fingers  into  the  patient's  mouth  are  superfluous.     The  tube  can  always  be 


Fig.  12.— Hemmeter's  Double-current  Stomach  Lavage  Tube. 
A.  Hard  rubber  inflow.     ^.  Soft  rubber  double  tube.     C  Hard  rubber  part  of  outflow.     Z>.  Stop- 
cock controlling  inflow.     E.  Reservoir.     F.  Outfllow  openings.     G.  Soft  outflow  tube.     /.  In- 
flow opening. 


introduced  without  a  guide,  and  without  touching  the  patient.  The  main  object 
is  that  the  point  of  the  tube,  when  it  has  reached  the  wall  of  the  pharynx,  shall 
be  deflected  downward.  This  will  occur  without  exception,  and  in  a  very  nat- 
ural, easy  manner,  if  the  patient  is  directed  to  swallow  at  this  moment.  In  the 
moment  of  this  act  of  deglutition  the  point  of  the  tube  is  bent  downward  into 
the  esophagus  ;  the  physician  must  carefully  watch  this  moment,  and  at  the  very 
onset  of  the  act  of  swallowing  rapidly  push  the  tube  over  the  descending  epi- 
glottis. If  the  patient  should  show  difficulty  in  breathing  after  the  tube  is  intro- 
duced, leave  it  quietly  in  place  and  encourage  the  patient  to  breathe  deeply. 
Boardman  Reed  ("International  Medical  Magazine,"  Oct.,  1898,  p.  693)  has 
correctly  observed  that  the  nervous  spasm  of  the  glottis  occasionally  encoun- 
tered during  the  introduction  is  relieved  by  "bringing  into  action  the  auxiliary 
respiratory  muscles  and  making  rhythmical  forced  inspirations." 

Beginners  in  using  the  tube  need  have  no  fear  that  it  will  enter  the  trachea. 
To  inake  it  enter  the  trachea  is,  in  the  writer's  experience,  a  difficult  undertak- 
9 


I20 


STOMACH-TUBE   AND   TECHNICS    OF    ITS    INTRODUCTION. 


ing,  and  requires  special  training  and  dexterity.  He  was  present  on  an  occa- 
sion when  a  class  of  ten  students  were  taking  a  private  course  in  diseases  of 
the  throat,  during  which  lesson  they  were  trying  to  mop  the  larynx.  What 
they  really  did  was  to  mop  out  the  superior  portion  of  the  esophagus,  showing 
plainly  that  it  is  not  as  easy  to  enter  the  larynx  as  the  esophagus.  Direct  the 
patient  to  keep  taking  deep  inspirations,  and  as  soon  as  the  tip  or  point  of  the 
tube  is  felt  touching  the  pharyngeal  wall,  tell  him  to  swallow,  and  almost 
immediately  the  tube  follows  into  the  esophagus  and  can  be  pushed  into  the 
stomach  without  further  resistance.  The  double  tube  is  still  in  its  experimental 
stage  and  can  not  be  recommended  as  practical.  Personally,  I  use  the  single 
tube  almost  exclusively. 


Fig.  13. — Illustrating  the  Principle  of 

SiPHONAGE. 


Fig.  14. — Bulb  Used  for  the  Aspiration 
OF  Test-meals  with  Patients  having 
\'erv  Rela-xed  Abdominal  Walls. 

A.  Stomach  end.  B.  End  going  to  collect- 
ing flask. 


It  is  not  necessarv'  for  the  patient  to  open  his  teeth  any  wider 
than  just  to  admit  the  tube;  at  the  same  time,  caution  him  not  to 
bite  on  it,  but  to  breathe  naturally.  In  case  the  tube  is  to  be  intro- 
duced into  highly  nervous  and  hysterical  patients,  or  such  who 
have  not  sufficient  self-control,  it  is  best  to  have  their  hands  held 
by  a  trained  nurse  or  assistant.  It  is  always  best  to  use  both  hands 
in  pushing  the  tube.     After  it  has  passed  the  glottis,  catch  hold  of 


CONTRAINDICATIONS    TO    LAVAGE.  121 

the  tube  two  inches  from  the  mouth  and  rapidly  complete  the  intro- 
duction. Avoid  seizing  the  tube  further  away  from  the  mouth, 
as  then  it  will  kink  on  pushing  it.  Xo  patient  should  be  subjected 
to  gastric  lavage  without  a  previous  examination  of  the  thorax. 
Penzoldt  tells  of  a  case  in  which  the  stomach  should  have  been 
washed  out  in  the  morning,  but  on  account  of  lack  of  time  this  was 
postponed  until  the  evening.  On  the  same  afternoon  the  patient 
died  of  rupture  of  an  aortic  aneur}'sm  into  the  esophagus. 
Lavage  and  introduction  of  the  tube  are  contraindicated — 
I.  In  all  constitutional  and  local  conditions  which  could  be  aggra- 
vated or  life  endangered  by  the  irritation  and  exertion  of  lavage. 
Among  these  could  be  mentioned: 

1.  Pregnancy. 

2.  Heart  disease  in  a  state  of  defective  compensation — ^heart 
neuroses,  angina  pectoris,  myocarditis,  and  fatty  heart  in  an  ad- 
vanced stage. 

3.  Aneur\'sm  of  the  large  arteries. 

4.  Recent  hemorrhages  of  all  kinds,  including  apoplexies,  pul- 
monary^, renal,  vesical,  gastric,  rectal  hemorrhages,  and  hemorrhagic 
infarctions. 

5.  Advanced  pulmonary  tuberculosis. 

6.  Advanced  pulmonan,'  emphvsema,  with  bronchitis. 

7.  Apoplexy  and  cerebral  hyperemia. 

8.  Advanced  cachexia. 

9.  Presence  of  continued  or  remittent  fever. 

II.  The  stomach  and  intestinal  diseases  which  are  contraindica- 
tions for  the  use  of  the  tube  are : 

1.  Ulcer,  with  recent  hematemesis  and  evidences  of  blood  in  the 
stools. 

2.  Palpable  carcinoma  of  the  pylorus,  with  vomiting  of  coffee- 
ground  material  and  the  classical  symptoms  of  cancer. 

3.  Stomach  or  intestinal  troubles,  with  acute  fever. 

4.  Gastric  mucosa  easily  started  to  bleeding. 

5.  Secondary^  gastric  affections  whose  dependence  upon  a  distinct 
and  more  important  primary  disease  is  evident. 

These  are  not  invariable  rules,  however;  cases  may  occur  under 
some  of  these  exceptions  that  at  times  peremptorily  require  lavage 
on  account  of  depressing  self-intoxication  from  the  stomach  or 
advanced  gastric  fermentation.  Thus,  according  to  Boas,  it  has 
been  employed  with  success  in  pregnancy,  and  the  author  has  washed 


122         STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 

out  the  stomach  in  cases  of  typhoid  fever  with  favorable  result, 
and  also  performed  lavage  in  a  case  of  aortic  regurgitation,  with 
Bright's  disease  and  gastrectasia,  where  much  relief  was  experienced 
from  the  procedure.  Professor  Moritz  has  frequently  passed  the 
stomach-tube  in  pregnant  women  to  ascertain  the  intragastric 
pressure  (25). 

In  a  normal  position  of  the  abdominal  viscera  the  location  of  the 
cardia  corresponds  to  the  spinous  process  of  the  ninth  thoracic 
vertebra.  By  counting  off  this  process  on  the  back  of  the  patient 
and  placing  the  upper  eye  of  the  tube  against  it,  one  can  measure 
the  length  of  tube  necessary  to  reach  the  stomach  by  applying  it 
from  this  point  along  the  back,  passing  alongside  of  the  ear  to  the 
front  incisor  teeth.  At  this  point,  which  reaches  the  incisors,  it  is 
of  assistance  to  make  a  mark  on  the  rubber  with  ink  or  to  tie  a  string 
around  it;  this  will  avoid  passing  the  tube  out  or  in  to  discover 
whether  it  has  reached  the  stomach  after  being  introduced. 

In  dilatations  and  falling  of  the  organ,  the  length  of  tube  required 
can  only  be  learned  after  a  previous  lavage.  When  the  tube  is 
used  to  draw  out  a  test-meal,  direct  the  patient  to  contract  his 
abdominal  muscles  as  if  in  the  act  of  having  a  stool.  Frequently 
the  accompanying  nausea  will  bring  this  about  involuntarily.  If 
no  contents  arise,  push  the  tube  gently  further  in  or  pull  it  slowl)'- 
out,  trying  different  levels.  If  the  abdominal  walls  are  flabby, 
external  manual  compression  will  sometimes  produce  the  desired 
result.  If  all  these  manipulations  are  of  no  avail,  the  stomach  is 
either  empty  or  the  tube  is  plugged  up  with  food-particles  too  large 
to  pass. 

To  find  out  which  is  the  case,  allow  300  c.c.  of  pure  water  to  run 
in  and  then  lower  the  funnel  and  siphon  out;  if  nothing  but  com- 
paratively clear  water  returns,  the  test-meal  has  passed  into  the 
duodenum.  One  should  be  very  cautious  in  moving  the  tube  out 
and  in  when  no  stomach  contents  appear  in  the  funnel,  as  it  is  pos- 
sible that  the  eyes  of  the  tube  may  have  sucked  in  the  gastric  mucosa 
itself,  and  by  moving  too  suddenly,  a  piece  may  be  torn  away.  If 
there  is  the  least  resistance,  avoid  moving;  rather  force  a  little  air 
through  the  tube  with  a  rubber  bulb  or  pour  in  a  small  amount  of 
water,  which  will  push  away  the  adherent  mucosa  or  the  food-par- 
ticle, and  the  next  attempt  will  bring  up  the  test-meal. 

If  the  stomach  is  already  empty,  the  test-meal  must  be  given 
again  at  another  time.     I  do  not  recommend  any  apparatus  for 


TEST-MEALS.  123 

aspiration,  not  even  the  rubber  bulb,  except  in  cases  of  advanced 
dilatation  or  relaxed  abdominal  walls,  when  the  rubber-bulb  aspir- 
ator becomes  necessar)- ;  with  patience  the  simple  expression  method 
will  suffice.  For  small  samples  of  test-meals  the  Einhom  stomach 
bucket  (Einhorn,  "Diseases  of  the  Stomach,"  p.  63)  is  an  available 
instrument.  Before  using  the  tube,  all  artificial  teeth  should  be 
removed,  and  tight  apparel,  especially  corsets,  should  be  loosened. 

In  very'  rare  cases  of  intense  food  and  mucous  putrefaction,  and 
in  extensive  gastrectasis,  a  recurrent  tube  may  be  used  with  success. 
To  give  an  idea  of  the  time  it  takes  to  cleanse  some  stomachs,  we 
quote  Dr.  Herman  Strauss,  assistant  to  Professor  Riegel,  who  claims 
to  have  washed  out  rice-particles  after  forty  liters  of  water  had  been 
allowed  to  flow  in  and  out.  After  personally  washing  a  dilated 
stomach  for  one  hour,  we  found  bread  and  stringy  mucus  in  the  last 
washing.  F.  B.  Turck  asserts  that  food  remnants,  even  after  the 
stomach  has  been  washed  clear,  may  adhere  to  the  walls  of  the 
organ ;  for  the  removal  of  these  he  recommends  his  gyromele  (' '  Chi- 


FiG.  15. — The  Esophageal  Tubal  Probe. 

cago  Clin.  Review,"  1895).  From  examination  of  many  hundred 
stomachs  at  autopsies  we  should  judge  that  food  adherence  to  the  wall 
of  the  stomach  occurs  very  rarel}^ 

Test-meals. — The  test-meal  most  frequently  employed  is  that 
of  Ewald  and  Boas,  consisting  of  a  roll  or  a  piece  of  wheat-bread 
and  500  c.c.  of  water  or  tea,  without  milk  or  sugar.  The  time  for 
examination  is  one  hour  after  the  meal. 

Leube  and  Riegel  advocate  a  test-dinner  of  400  c.c.  soup,  a  por- 
tion of  beefsteak  or  roast  beef,  potatoes,  and  a  roll.  The  time  for 
examination  is  three  to  four  hours  after  this  meal. 

Jaworski  and  Gluczinski  employ  the  white  of  a  hard-boiled  egg 
and  100  c.c.  water. 

Klemperer  recommended  ^4  of  a  liter  of  milk  and  70  gm.  of  wheat- 
bread,  and  examined  two  hours  later. 

Germain  See  used  60  to  80  gm.  scraped  meat  and  150  gm.  white 
bread.     Examination  two  hours  later. 

The  Ewald  and  Boas  test-breakfast  seems  the  most  convenient, 
and  in  cases  of  enfeebled  digestion,  when  much  food  is  retained  from 
previous  meals,  the  least  confusing.  . 


124         STOMACH-TUBE   AND   TECHNICS    OF    ITS    INTRODUCTION. 

Kleiner's  test-meal  consists  of  soup,  roast  beef,  and  potato  puree; 
he  examines  three  to  four  hours  after  the  meal. 

Double  Test-meal  Used  by  the  Author. — At  our  clinic,'the  Hospital 
of  the  University  of  Maryland,  we  generally  use  a  double  test-meal, 
consisting  of: 

8  A.  M. — One  small  piece  of  beef,  scraped  and  broiled  =  80  gm. ;   i  soft-boiled 
egg  ;  30  gm.  boiled  rice  ;  i  glass  of  milk  =  250  c.c,  and  a  piece  of  bread. 

Four  to  five  hours  later  an  Ewald  test-meal  is  given,  and  one  hour 
after  this  the  stomach  contents  are  drawn.  In  giving  a  test-meal, 
always  insist  on  good  chewing,  and  urge  that  all  food  substances  be  very 
finely  cut  up,  so  that  they  can  not  plug  up  the  tube,  even  if  not  digested. 

The  double  test-meal,  about  which  the  late  Dr.  Henry  Salzer,  of 
Baltimore,  was  quite  enthusiastic,  really  offers  some  advantages 
over  others.  In  the  first  place,  it  permits  of  as  easy  a  study  of  the 
various  stages  of  the  digestion  and  of  the  motility  and  degree  of 
retention  as  Riegel's  test-dinner;  but  the  main  advantage  of  the 
double  test-meal — a  full  meal  at  8  or  9  a.  m.  and  an  Ewald  test- 
meal  at  12  M.  or  I  p.  M.,  examination  at  i  or  2  p.  m. — is  that,  after 
drawing  it,  we  may,  in  a  large  number  of  instances,  recognize  con- 
ditions of  gastric  motility  and  secretion  before  we  analyze  the  con- 
tents. For  instance,  disappearance  of  the  entire  breakfast-meal 
points  to  a  normal  digestion. 

Absence  of  all  proteids, — beef  and  egg, — and  presence  of  consider- 
able carbohydrates, — rice  and  bread, — point  to  hyperchlorhydria ; 
and,  again,  absence  of  all  carbohydrates  and  presence  of  some  of  the 
beef  and  egg  point  to  hypochlorhydria,  subacidity,  anacidity  or 
achylia.  Presence  of  the  entire  meal,  with  perhaps  milk  uncurdled, 
means  impaired  motility,  with  atrophy  of  gastric  mucosa,  absence 
of  acid,  enzymes,  and  proenzymes.  If  the  entire  meal  has  disap- 
peared, the  status  of  the  gastric  secretions  may  be  ascertained  from 
the  Ewald  test-meal,  which  is  still  present. 

The  objection  which  has  been  made,  that  the  double  meal  is  un- 
cleanly to  handle  during  analysis,  has  also  been  urged  against  Riegel's. 
Whether  the  morsels  of  an  Ewald  test-meal  are  nicer  and  more 
esthetic  to  handle  than  remnants  of  our  double  test-meal  is  a  matter 
concerning  which  it  does  not  pay  to  quarrel.  It  is  a  very  important 
matter  to  state  what  test-meal  is  used  in  giving  out  the  various 
acidities  obtained,  because  some  test-meals  are  greater  stimulants  to 
the  gastric  secretion  than  others. 


AMOUNTS   OF   ACIDS   SECRETED  AFTEiR   TEST-MEALS. 


125 


The  Ewald  test-breakfast  really  makes  very  slight  demands  upon 
the  working  capacity  of  the  stomach. 

The  total  acidity  one  hour  after  an  Bwald  test-breakfast  is  nor- 
mally about  60*;  the  lowest  total  acidity  observed  by  us  one  hour 
after  a  test-breakfast  of  this  kind  in  a  healthy  individual  was  22. 


Fig.  16. — Stomach-pump  used  qnly  for  Rapid  Evacuation  of  Poisons. 

Kleiner,  who  uses  a  test-meal  of  soup,  roast  beef,  and  potato  puree, 
asserts  that  two  to  three  and  a  half  hours  after  this  test-meal  the 
total  acidity  is  normally  70  to  100  (Prof.  Wilhelm  Fleiner,  "Lehrbuch 
d.  Krankheiten  d.  Verdauungsorgane,"  p.  186).     Dr.  Julius  Frieden- 


*  For  the  significance  of  these  figures  the  reader  is  referred  to  the  chapter  on  Titration 

of  Stomach  Contents. 


126         STOMACH-TUBE   AND   TECHNICS    OF    ITS    INTRODUCTION. 

wald  has  confirmed  that  the  gastric  secretion  of  HCl  appears  sooner 
and  reaches  a  higher  degree  after  the  double  test-meal  than  after  an 
Kwald  meal. 

An  amount  of  HCl  equal  to  o.i  to  0.25  per  cent,  may  be  regarded 
as  normal;  above  this,  is  hyperacidity.  The  total  acidity  can  not 
correctly  be  regarded  as  an  unfailing  indication  of  the  amount  of 
HCl  present;  the  latter  should  always  be  determined  separately  in 
addition  to  the  total  acidity. 

Apparently  there  are  climatic,  barometrical,  and  geographical  fac- 
tors which  influence  the  total  acidity.  In  170  cases  at  Riegel's 
clinic,  Strauss  found  the  total  acidity  after  a  test-breakfast  equal  to 
68;  in  92  cases  at  Berlin  after  a  test-breakfast  the  average  total 
acidity  was  estimated  at  47;  the  average  amount  of  free  hydro- 
chloric acid  at  Riegel's  clinic  was  found  to  be  37.  Normal  values 
one  hour  after  a  test-breakfast  of  a  roll  and  water  are,  for  average 
total  acidity,  40  to  60;  for  free  HCl,  20  to  30,  for  our  clinic  at  the 


Fig.  17. — Modified  Ewald  Tube,  with  numerous  smaller  and  larger  Lower  Openings. 


University  of  Maryland,  Baltimore,  and  in  private  practice.  These 
were  also  the  figures  obtained  formerly  at  the  Maryland  General 
Hospital. 

Four  hours  after  the  complex  meal  of  Salzer, — i.  e.,  50  to  60  grs. 
beef,  500  c.c.  milk,  70  grs.  rice,  and  one  Q:gg, — the  total  acidity  on 
the  average  was  found  to  be  95  and  the  free  HCl  46,  at  the  author's 
clinic.  It  should  be  emphasized  that  these  figures  represent  only 
relative  values.  One  often  finds  every  symptom  of  hyperacidity 
with  relief  following  the  use  of  alkalies,  when  the  total  acidity  was 
found  to  be  only  56  (one  hour  after  an  Ewald  breakfast),  the  free 
HCl  only  24.  On  the  other  hand,  cases  have  presented  themselves 
showing,  under  the  same  conditions,  a  total  acidity  of  80  and  free 
HCl  =  50,  still  no  symptoms  of  hyperacidity.  All  this  goes  to  show 
that  some  stomachs  may  do  their  work  normally  very  well  on  relatively 
low  amounts  of  free  HCl,  and,  of  course,  suffer  from  hyperacidity 
from  comparatively  slight  increase  of  free  HCl,  which  would  not  affect 


LITERATURE    ON   THE    STOMACH-TUBE.  1 27 

a  stomach  used  to  higher  amounts  of  acid.  (See  Hemmeter,  "  Archiv 
fiir  Verdauungskrankheiten, "  Bd.  iv,  S.  30.) 

Most  observers  that  can  speak  with  authority  on  the  subject  agree 
that  the  total  acidity  should  not  be  employed  to  express  hyper- 
acidity, but  only  the  amount  of  free  HCl,  as  this  is  the  only  acid 
which,  when  increased,  gives  rise  to  the  complex  of  symptoms  tech- 
nically recognized  as  hyperacidity. 

Before  closing  this  chapter  it  might  be  added  that,  where  it  is 
impossible  to  use  the  tube  on  account  of  prejudice  of  the  patient,  to 
obtain  a  test-meal,  emesis  may  be  resorted  to.  The  stomach  con- 
tents obtained  after  a  test-meal,  as  a  rule,  filter  slowly,  and  if  much 
mucus  is  present,  with  great  difficulty.  The  filtration  can  be  accel- 
erated by  rubbing  the  material  first  through  a  small,  coarsely  grained 
sieve  (strainer),  then  through  a  finely  grained  strainer,  and  then 
filtered  through  Swedish  filter-paper. 


LITERATURE 

ON   THE   HISTORY   AND   TECHNICS   OF   THE   STOMACH-TUBE. 

1.  Abercrombie,  "  Diseases  of  the  Stomach." 

2.  Arnott,  quoted  by  Alderson,  on  the  "  Dangers  Attending  the  Use  of  the 
Stomach-pump,"  "  Lancet,"  January  4,  1879. 

3.  Avicenna,  "Liber  Canonis,"  etc.,  1544,  Ausg.  Venice,  Liber  i,  fen.  iv, 
Chap.  XX,  p.  83. 

4.  Benedict,  A.  L.,  "Conservatism  in  the  Use  of  the  Stomach-tube,"  "Am. 
Med.  and  Surg.  Bull.,"  1898,  xii. 

5.  Berger,  C,  "  Ueber  die  Technik  der  Einfiihrung  des  Magenschlauches," 
"Reich's  Med.  Anz.,"  Leipzig,  1898,  xxiii. 

6.  Bush,  F.,  "  London  Medical  and  Physic.  Journal,"  1822. 

7.  Canstatt,  "Text-book,"  Erlangen,  1846,  Vol.  ill,  Cap.  vi. 

8.  Capivacceus,  Hieronymus,  "  Medic.  Practic,"  Liber  i.  Cap.  liii,  Venice, 
1590. 

9.  Dapper,  "Die  unbekannte  neue  Welt,"  etc.,  Amsterdam,  1753,  S.  566. 

10.  Ewald,  C.  A.,  "  Klinik  d.  Verdauungskrankheiten,"  Berlin,  i890-'9l. 

11.  Ewald,  C.  A.,  "A  Ready  Method  of  Washing  Out  the  Stomach,"  "Irish 
Gazette,"  August  15,  1874. 

12.  Hemmeter,  John  C,  "  An  Apparatus  for  Washing  Out  the  Stomach  and 
Sigmoid  with  a  Continuous  Current,"  etc.,  "  New  York  Med.  Journal,"  March 
30,  1895. 

13.  "  Hieronym.  Fabric,  ab  Abquapendente,"  "  Chirurg.  Schrift,"  ed.  Joh. 
Scultetus,  Nurnberg,  1716,  11  Theil,  Cap.  39,  S.  92. 

14.  Hieronymus  Mercurialis,  "Die  Morbis  venenosis  et  venenis,"  Venetiis, 
1583,  Liber  i.  Cap.  22. 

15.  Hunter,  John,  "Proposals  for  the  Recovery  of  People  Apparently 
Drowned,"  "  Sammlung  auserlesener  Abhandlungen,"  iv,  S.  144. 


128  literature;  on  the  stomach-tube. 

i6.  Jackson,  "Extracts,"  "Records  of  the  Boston  Society  for  Medical  Im- 
provement," Vol.  VI,  p.  261. 

17.  Jiirgensen,  "  Zur  lokal.  Therapie  der  Magenkrankheiten,"  "  Deutsch. 
Archiv  f.  klinische  Medizin,"  Band  vir,  p.  239,  1870. 

18.  Knapp,  M.  J.,  "The  Clinical  Report  of  Four  Cases  of  Lavage  of  the 
Stomach  by  the  Aid  of  Knapp's  Director,"  "  Med.  Rec.-,"  New  York,  1898, 
LHi,  313. 

19.  Kussmaul,  "  Behandl.  d.  Magenerweit.  durch  eine  neue  Methode,  mit  der 
Magenpumpe,"  "  Deutsch.  Archiv  f.  klinische  Med.,"  vi,  455. 

20.  Leube,  "Die  Magensonde,"  Erlangen,  1879. 

21.  Leube,  "  Deutsche  Archiv  f.  klinische  Med.,"  Band  xxxiii. 

22.  Martius  and  Liittke,  "  Die  Magensaure,"  Stuttgart,  1892. 

23.  Moritz,  "Zeitschrift  f.  Biologie,"  xxxii,  p.  314,  Leipzig,  1895. 

24.  Murdoch,  F.  H.,  "  The  Use  and  Abuse  of  the  Stomach-tube,"  "  N.  Y. 
Med.  Jour.,"  16,  i,  1897. 

25.  Nicander,  "Alex.  Phar.,"  Edit.  Paris,  1857,  p.  155. 

26.  "  Oribasius,  Collecta  medicinalia  of,"  Vol.  viii.  Cap.  vi. 

27.  Pechlini,  Joh.  Nicol.,  "Observation  Physico-medical,"  Liber  i,  observ. 
50,  S.  116,  Hamburg,  1691. 

28.  Penzoldt,  F.,  "  Allgem.  Behandl.  d.  Magen-  u.  Darmkrankheiten,"  in 
"  Handbuch  der  speciell.  Therapie  innerer  Krankh.,"  Vol.  iv,  p.  289. 

29.  Penzoldt,  F.,  "Die  Magenerweiterung,"  Erlangen,  1875. 

30.  Ploss,  "  Der  Magenkatheter  a  Double  Courant,"  etc.,  "  Deutsche 
Klinik,"  1870,    No.  8. 

31.  Reed,  B.,  "  How  to  Introduce  a  Tube  into  the  Stomach  with  the  Least 
Possible  Embarrassment  of  the  Patient,"  "Internal.  Med,  Mag.,"  Phila., 
1898,  VII. 

32.  Rosenheim,  "  Krankheit.  d.  Speiserohre  u.  d.  Magens,"  Wien  und  Leip- 
zig, 1891. 

33.  Rumssus,  "  Organum  Salutis,  or  an  Instrument  to  Cleanse  the  Stomach," 
1649. 

34.  Ryff,  W.  H.,  "Gross.  Chirurgie,"  Frankfurt-a.-M.,  1559,  Theil  i,  p.  37. 

35.  Scultetus,  Joh.,  "  Wundartzneyisches  Zeughaus,"  Frankfurt,  Ulm,  1679, 
S.  108. 

36.  Socrates,  J.  C,  "  Griindliche  u.  voUstandige  Beschreib.  d.  Peniculi  Ven- 
triculi  Singularis,"  etc..  Lips,  u.  Frankfurt,  1713;  "  Breslauer  Sammlung  von 
Natur  u.  Medizin,"  etc.;    "Geschichten,"  1719,  Classe  v.  Art.  in. 

37.  Sorbierus,  in  "  Sorberiana,"  Paris,  1694. 

38.  Van  Helmont,  "Doctrina  inaudita  de  causa,"  etc.,  "  Lithiasis,"  1646, 
Cap.  VII,  34,  S.  140. 

39.  Veronensis,  Joh.  Arculani,  "  Practica,"  etc.,  Venice,  1557,  p.  82. 

40.  Welch,  William  H.,  Pepper's  "American  System  of  Medicine,"  Vol.  11, 
p.  607. 


ANALYSIS    OF    STOMACH    CONTENTS.  1 29 


CHAPTER  XIII. 

METHODS  FOR  QUALITATIVE  AND  QUANTITATIVE 
ANALYSIS  OF  STOMACH  CONTENTS. 

Presence  of  Bits  of  Gastric  Mucosa. — Examination  of  Stomach  Contents 
for  Mucus,  Saliva,  Bile,  Duodenal  Secretions,  Blood,  and  Pus. — 
Tests  for  Blood  in  Stomach  Contents. — Demonstration  of  the  Presence 
of  Iron  in  Stomach  Contents  or  Vomited  Matter. — Spectroscopical 
Examination  of  Stomach  Contents  for  Blood. — Examination  of  Por- 
tions of  Mucosa  or  Tissue  found  in  the  Wash-water  or  Vomited 
Matter. — Literature. 

The  stomach  contents  should  be  examined  for — 

1.  The  character  and  amount  of  the  undigested  food. 

2.  The  presence  and  kind  of  bacteria  and  yeast  fungi. 

3.  The  bile,  mucus,  pus,  and  blood. 

4.  The  total  acidity. 

5.  The  amount  of  free  hydrochloric  acid. 

6.  The  presence  of  inorganic  acids,  as  lactic,  butyric,  or  acetic 
acids. 

7.  The  combined  hydrochloric  acid  and  acid  salts. 

8.  The  presence  of  products  of  digestion, — viz.,  syntonin,  pro- 
peptone,  albumoses,  peptone. 

9.  The  presence  of  pepsin  and  rennin;  if  these  are  absent,  their 
proenzymes. 

10.  The  products  of  starch  digestion,  dextrin,  erythrodextrin, 
achroodextrin,  and  maltose. 

1 1 .  Fragments  of  mucosa. 

12.  Fragments  of  neoplasms. 

Character  and  Amount  of  Undigested  Food. — The  examina- 
tion for  undigested  food-particles  may  demonstrate  the  presence 
of  substances  eaten  twenty-four  hours  before  the  expression  of 
contents,  and  thus,  at  once,  establish  an  atony,  dilatation,  or  stenosis. 
As  already  pointed  out,  excess  of  rice  and  bread  and  absence  of 
beef  and  egg  indicate  a  higher  acidity,  while  absence  of  bread  and 
rice  and  presence  of  &gg  and  beef  indicate  sub-  or  anacidity.  This, 
of  course,  can  be  most  conveniently  studied  when  the  contents  are 


I30  ANALYSIS    OF  STOMACH    CONTENTS. 

drawn  out  about  five  hours  after  the  first  of  the  double  meal,  as 
employed  by  the  author. 

Bacteria. — For  bacteriological  examination,  a  few  slides  are 
stained  with  methylene-blue,  and  also  cultures  made,  the  latter 
especially  when  there  is  any  disease  of  the  air-passages  the  microbes 
of  which  may  get  into  the  stomach  with  swallowed  mucus  or  run 
down  unconsciously  during  sleep.  This  is  particularly  important 
in  pulmonary  or  laryngeal  tuberculosis.  Instead  of  methylene-blue, 
IvUgol's  solution  of  iodin  should  be  used  on  other  slides  for  examining 
bits  of  tissue,  mucosa,  and  cellular  detritus. 

The  normal  stomach  contains  many  micro-organisms;  only  the 
presence  of  very  large  numbers  of  bacteria  has  a  pathological  sig- 
nificance, if  by  culture  experiments  they  can  be  shown  to  be  still 
capable  of  multiplication. 

Microbes  only  propagate  luxuriantly  when  stagnation  of  gastric 
contents  occurs.  The  secretory  disturbances  are  then  a  secondary- 
effect,  a  consequence  of  the  stagnation.  But  primary  reduction  of 
HCl  secretion  has  been  known  to  cause  a  luxuriant  gastric  flora, 
since  it  is  the  HCl  which,  to  a  great  extent,  inhibits  their  develop- 
ment and  also  destroys  a  large  number  of  them.  If  there  be  deficient 
peristaltic  power,  the  diminution  of  HCl  causes  further  disturbances 
in  the  stomach  and  intestines  by  accumulation  of  bacteria.  But 
no  degree  of  gastric  acidity,  no  matter  how  great,  can  destroy  all 
bacteria  introduced. 

Germ  growth  in  the  walls  of  the  stomach  and  in  adherent  food- 
masses  has  been  reported  by  F.  B.  Turck  ("N.  Y.  Med.  Joum.," 
Nov.  23,  1895).  This  has  been  observed  by  us  in  ulcer,  ulcus  car- 
cinoma tosum,  and  carcinoma. 

Hyperacidity  is  as  detrimental  in  its  consequences  as  anacidity, 
because  it  inhibits  normal  intestinal  digestion,  which  is  the  best 
means  of  combating  fermentation  and  putrefaction.  Hydrochloric 
acid  undoubtedly  inhibits  or  checks  gastric  fermentation  to  a  certain 
extent,  but  all  ferment-producing  microbes  are  not  destroyed  by  it 
in  the  stomach.  Therefore,  one  frequently  finds  gastric  fermenta- 
tion with  hyperacidity  of  HCl,  and,  reversely,  fermentation  may 
be  absent  where  hydrochloric  acid  is  entirely  absent,  provided  the 
peristole  is  good. 

This  will  again  impress  the  importance  of  an  intact  gastric  peris- 
talsis, a  certain  time  of  action  being  indispensable  for  organized 
ferments  to  set  up  their  characteristic  decomposition  even  at  the 


BACTERIA   OF   THE   STOMACH. 


131 


body  temperature ;  with  a  good  motility,  however,  the  gastric  chyme 
may  reach  the  intestine,  meeting  a  vigorous  digestion  before  the 
bacteria  get  a  chance  to  forge  ahead  of  the  normal  unorganized 
ferments. 

The  most  frequent  of  fungi  in  gastric  contents  is  ordinary  yeast, 
and  there  should  be  no  difficulty  in  recognizing  it.  Unless  occur- 
ring in  large  numbers  and  sprouting,  it  has  no  pathological  signifi- 
cance. Two  more  germs  found  in  the  contents  are  of  interest — the 
sarcinse  and  the  Oppler-Boas  bacillus,  the  latter  occurring  in  the 
gastric  contents  of  carcinoma.  Sarcinse  may  be  seen  under  the 
microscope  without  staining;  they  are,  indeed,  preferably  to  be  ex- 
amined that  way,  as  they  stain  so  deeply  with  anilin  dyes  as  to  look 
like  black  patches. 

Sidney  Martin  recommends  drying  and  fixing  a  drop  of  stomach 
contents  on  the  slide  or  cover- 
glass,  and  placing  in  a  very 
dilute  solution  of  gentian  vio- 
let for  three  minutes,  washing 
out  in  water,  drying,  and 
mounting  in  Canada  balsam. 
The  gentian  violet  must  be  so 
diluted  as  to  be  nearly  trans- 
parent. Yeast  can  similarly  be 
stained  by  magenta  or  methyl- 
ene-blue  solution  (two  per 
cent.).  If  the  latter  is  used,  the 
preparation  requires  washing 
out  in  water. 

Sarcinse  can  hardly  be  said 
to  have  any  pathological  significance,  according  to  Oppler  ("Miinchen. 
med.  Wochenschr.,"  1894,  No.  29).  They  are  found  in  ectasias,  occur- 
ring on  a  nonmalignant  basis,  and  in  very  atonic  conditions ;  also  in 
acute  and  chronic  gastritis,  in  ulcer,  in  the  gastric  neuroses,  and  the 
gastroptoses ;  in  the  last-named  conditions  the  presence  of  sarcinae  is 
rather  the  exception  than  the  rule. 

Riegel  agrees  with  Oppler  in  the  assertion  that  sarcinse  are  very 
rarely  found  in  gastric  carcinoma.  They  are  generally  observed  in 
biscuit  or  bale-shaped  groups  of  four,  eight,  and  sixteen  individual 
sarcinae  bunched  together;  their  occurrence  as  single  individuals  is 
seen  rarely. 


Fig.  18. — Oppler-Boas  Bacillus  from  Contents 
OF  A  Carcinomatous  Stomach. 


132  BACTERIA    OF    THE    STOMACH. 

The  Oppler-Boas  bacillus  (Oppler,  "2ur  Kenntniss  d.  Magenin- 
halts  bei  Carcinoma  Ventriculi,"  "Deutsche  med.  Wochenschr.," 
1895,  No.  5)  is  an  unusually  long  and  non-motile  bacterium,  which 
was  observed  in  many  cases  of  gastric  carcinoma.  (See  Fig.  18.)  In 
twenty  cases  of  carcinoma  Kaufmann  found  these  bacilli  nineteen 
times,  and,  according  to  his  investigations,  they  have  the  power  of 
abundantly  forming  lactic  acid  from  various  kinds  of  sugar.  In 
the  only  case  of  the  twenty  just  mentioned  in  which  the  Oppler- 
Boas  bacillus  was  absent,  the  lactic  acid  was  absent  also. 

According  to  Schlesinger  and  Kaufmann  ("Wiener  klinische 
Rundschau,"  1895,  No.  15),  the  presence  of  a  large  number  of  these 
bacilli  in  the  stomach  contents  is  an  indication  of  carcinoma,  and 
their  absence  is  of  similar  significance  to  the  absence  of  lactic  acid. 
If  a  stenosis  of  the  p5dorus  is  present,  then  the  absence  of  these 
bacilli  is  an  argument  against  carcinoma.  Riegel  {loc.  cit.)  confirms 
the  occurrence  of  these  bacilli  in  enormous  numbers  in  carcinoma, 
and  adds  that,  although  there  are  numerous  fungi  that  have  the 
property  of  forming  lactic  acid  in  stomach  contents,  this  can  not 
alter  the  significance  of  the  Kaufmann  and  Schlesinger  observation. 
He  does  not  consider  this  organism  as  pathognomonic  of  gastric 
cancer,  but  as  very  important  for  the  diagnosis.  Since  the  publica- 
tion of  the  first  edition  of  this  work,  the  writer  and  his  clinical  assist- 
ants have  examined  fifty  cases  of  gastric  carcinoma  particularly  for 
the  Oppler-Boas  bacillus.  They  were  found  in  every  case  but  one. 
We  examined  also  eighteen  cases  of  gastric  ulcer  without  discovering 
this  organism  in  a  single  case,  and  consider  this  examination  an 
indispensable  adjunct  to  every  gastric  analysis. 

Our  knowledge  concerning  the  bacteria  occurring  in  normal  and 
pathological  stomach  contents  is  very  incomplete  as  yet.  It  ap- 
pears, however,  that  in  all  pathological  processes  we  are  not  con- 
fronted with  qualitatively  new  bacteria,  but  with  excessive  multi- 
plication of  those  normally  present.  The  disturbances  produced  by 
abnormal  augmentation  of  bacteria  in  the  stomach  are  explained  by 
Minkowski  ("Ueber  d.  Gahrung  im  Magen,"  "Mittheilung  a.  d.  Med. 
Klin.  Konigsberg,"  edited  by  B.  Naunyn,  Leipsic,  1888,  p.  156)  in 
the  following  manner; 

1.  Substances  may  be  formed  which  irritate  the  mucosa  and  pro- 
voke catarrhal  inflammation. 

2.  Gas  may  be  formed  in  considerable  quantities,  causing  distress  by 
distention,  and  increase  the  mechanical  insufiiciency  already  present. 


MUCUS — BILE — BLOOD — PUS.  .  I33 

3.  The  fermentation  may  give  rise  to  toxins. 

4.  Putrefaction  of  albuminous  bodies  may  produce  alkaline  bodies 
that  will  neutralize  the  hydrochloric  acid  or  what  little  of  it  may 
yet  be  secreted. 

5.  Gastric  fermentations  may  have  a  detrimental  influence  on  the 
intestinal  functions. 

Examination  of  Stomach  Contents  for  Mucus,  Saliva,  Bile, 
Duodenal  Secretions,  Blood,  and  Pus. — The  presence  of  mucus 
is  evident  to  the  naked  eye  by  its  stringy  and  tenacious  character. 
Mucus  from  the  pharynx  is  distinguished  from  gastric  mucus  by  its 
occurring  in  clumps  and  being  discolored  by  dust-particles.  The 
chemical  demonstration  is  carried  out  by  dissolving  the  mucus  in 
liquor  potassae,  in  which  it  is  slightly  soluble,  and  from  which  it  can 
be  reprecipitated  by  acetic  acid.  When  pharyngitis,  laryngitis,  and 
bronchitis  can  be  excluded,  large  quantities  of  mucus  in  stomach 
contents  are  indicative  of  gastritis.  The  normal  stomach  does  not 
secrete  much  mucus.  Statements  repeatedly  made  to  the  contrary 
can  only  be  explained  by  faulty  clinical  observation.  Mucus  is 
dissolved  or  digested  by  gastric  juice,  but  requires  twice  as  long  as 
albumin  for  its  solution  (Schmidt,  "Deutsch.  Arch.  f.  klin.  Med.," 
Bd.  Lvii,  S.  72).  Gastric  mucus  may  occur  in  two  forms:  (i)  As  a 
glassy,  swollen,  transparent  mass;  (2)  in  forms  of  fibers  or  shreds. 
These  states  of  mucus  are  to  a  large  extent  conditioned  by  the  amount 
of  HCl  secreted.  When  there  is  a  deficiency  or  absence  of  HCl, 
the  mucus  swells  up.  When  HCl  secretion  is  normal  or  increased, 
the  miicus  may  be  increased  also,  but  if  so,  it  occurs  in  forms  of 
fibers,  strings,  or  shreds.  The  quantity  of  mucus  is  inversely  pro- 
portional to  the  quantity  of  HCl  secreted;  the  largest  amounts  are 
found  with  total  absence  of  HCl.  Microscopical  examination  of  the 
mucus  yields  unsatisfactory  results;  when  it  contains  pigmented 
alveolar  epithelia,  it  is  derived  from  the  respiratory  passages.  Pave- 
ment epithelium  suggests  its  origin  from  the  mouth  and  pharynx, 
but  if  the  gastric  juice  be  capable  of  digesting,  one  finds  only  nuclei, 
and  if  it  be  devoid  of  digestive  power,  entire  cells  are  found.  The 
spiral  or  snail  cells,  first  described  by  Jaworski,  are  products  of  the 
action  of  HCl  on  mucus,  and  have  no  diagnostic  significance. 

If  the  gastric  contents  consist  largely  of  saliva,  this  can  be  demon- 
strated by  the  potassium  sulphocyanate,  KCNS,  which  is  a  normal 
constituent  of  healthy  saliva.  Potassium  sulphocyanate  gives  a  dark, 
purplish-red  color  upon  the  addition  of  a  solution  of  chlorid  of  iron. 


134  ANALYSIS    OF   STOMACH    CONTENTS. 

Bile,  if  present  to  any  considerable  extent,  is  noticeable  at  once 
to  the  naked  eye  by  the  compound  greenish-yellow  tinge  it  imparts 
to  stomach  contents.  Very  slight  amounts  of  bile  and  duodenal 
secretions  are  occasionally  observed  under  normal  conditions,  par- 
ticularly if  the  stomach  be  washed  out  early  in  the  morning  before 
breakfast,  for  there  is  no  absolute  closure  of  the  pylorus  when  the 
stomach  is  empty. 

Boas  has,  however,  pointed  out  that  constant  presence  of  very 
evident  admixture  of  bile  and  duodenal  secretions  points  to  stenosis 
of  the  descending  portion  of  the  duodenum  (Boas,  "Deutsche  med. 
Wochenschr.,"  1791,  No.  28,  "Ueber  die  Stenose  des  Duodenum"). 
As  a  rule,  it  will  be  necessar}^  to  assure  one's  self  of  the  presence  of 
bile  by  the  Gmelin  test,  or  the  demonstration  of  bile  acids  or  choles- 
terin. 

Gmelin's  test  is  carried  out  by  adding  twenty  drops  of  fuming 
nitric  acid  to  ten  c.c.  of  officinal  nitric  acid  in  a  test-tube.  Ten  c.c. 
of  stomach  filtrate  are  drawn  into  a  pipet,  and,  holding  the  test- 
tube  with  the  HNO3  in  the  left  hand  in  a  slanting,  horizontal  position, 
the  filtrate  is  allowed  to  flow  slowly  from  the  pipet  held  in  the  right 
hand  over  the  nitric  acid.  If  the. stomach  contents  contain  bile, 
there  will  be  formed  several  characteristic  rings  of  color,  which, 
going  from  above  downward,  are  (i)  green,  (2)  blue,  (3)  violet,  and 
(4)  red,  but  only  the  green  color  is  an  evidence  of  the  presence  of  bile. 

Better  results  are  obtained  by  using  a  conical  glass  on  a  broad 
foot  instead  of  a  test-tube.  In  the  clinical  laboratory  they  are  of 
sixty  to  seventy-nine  c.c,  or  about  two  ounces,  in  capacity.  It  is  of 
some  advantage  to  be  able  to  place  them  alternately  on  and  in  front 
of  a  white  and  black  background  during  the  reaction.  First,  twenty 
c.c.  of  gastric  juice,  if  necessary  previously  filtered,  are  placed  in 
the  glass,  then  ten  c.c.  of  nitric  acid  added  by  a  pipet,  which  is  care- 
fully carried  to  the  bottom  of  the  vessel;  here  the  nitric  acid  is  very 
gradually  permitted  to  escape  by  diminishing  the  pressure  of  the 
finger  on  the  end  of  the  pipet.  In  this  manner  it  is  easier  to  get  the 
nitric  acid  under  the  gastric  juice.  The  display  of  the  colors,  yellow, 
green,  blue,  violet,  and  red,  occurs  from  above  downward ;  the  green 
color  is  the  only  one  that  is  characteristic  of  bile  elements. 

The  demonstration  of  the  bile  acids  is  effected  by  first  precipitating 
all  albuminous  bodies  by  boiling  or  by  alcohol ;  a  few  drops  of  a  solu- 
tion of  cane-sugar  are  added,  and  then,  drop  by  drop,  pure  con- 
centrated sulphuric  acid.     If  the  solution  is  now  heated,  a  beau- 


BLOOD   IN   GASTRIC   CONTENTS.  I35 

tiful  purple-red  color  is  obtained,  between  60°  and  70°  C.  (Petten- 
kofer). 

The  presence  of  duodenal  secretions  is  demonstrated  by  testing 
the  stomach  contents  for  the  specific  ferment  activity  of  trypsin, 
amylopsin,  and  steapsin.     (See  pp.  59,  60,  and  61.) 

Pus. — Pus  is  rarely  found  in  the  gastric  contents,  but  if  so,  puru- 
lent inflammations  in  the  mouth,  tonsils,  pharynx,  retronasal  fossae, 
larynx,  and  bronchi  must  be  excluded  before  assigning  its  cause  to 
the  stomach.  In  one  case  in  which  we  found  pus  in  the  stomach  it 
came  from  an  ozena ;  in  another  it  was  traced  to  a  tuberculous  soft- 
ening in  the  left  lung.  The  significance  of  pus  will  be  considered 
in  connection  with  acute  simple  and  with  phlegmonous  gastritis. 

Test  for  Blood  in  Stomach  Contents. — Although  blood  may  be 
present  in  the  material  drawn  by  a  stomach-tube,  or  in  vomit,  it  is 
not  always  easy  to  decide  whether  it  was  derived  from  the  lungs  or 
from  the  stomach.  Vomiting  may  produce  a  cough,  and,  vice  versa, 
coughing  may  lead  to  an  attack  of  vomiting;  ajid  in  cases  where 
either  organ  is  liable  to  hemorrhage,  as  in  tuberculous  patients  with 
a  congestive  state  of  the  gastric  mucosa,  it  is,  except  in  rare  instances, 
impossible  to  decide  the  origin  of  the  blood. 

In  cases  with  copious  arterial  gastric  hemorrhage,  the  blood  is 
bright  red  and  clotted.  A  slower  but  still  quite  profuse  hemorrhage 
generally  shows  as  a  black  clot  or  mass  of  black  clots.  In  very  slow 
but  continuous  hemorrhage  the  blood  collects,  and  may  be  partially 
digested  or  decomposed  in  the  stomach  before  it  is  vomited  as  a 
black,  coffee-ground  material.  The  diagnosis  of  blood  in  the  vomit 
is  not  always  easily  made.  There  are  four  methods  of  determining 
the  presence  of  blood,  and  by  one  or  more  of  them  it  may  generally 
be  accomplished. 

The  first  is  by  the  microscopical  demonstration  of  the  red  blood- 
corpuscles.  In  cases  of  suspected  ulcer,  all  vomited  matter  should 
be  microscopically  examined,  even  when  blood  is  not  evident  to  the 
naked  eye. 

The  second  is  known  as  the  guaiacum  test.  Two  or  three  drops 
of  freshly  prepared  tincture  of  guaiacum  are  added  to  five  c.c.  of 
stomach  contents  in  a  test-tube,  and  ozonized  ether  poured  on  the 
surface;  if  blood  is  present,  a  blue  color  develops  where  the  two 
liquids  meet.  Equal  parts  of  tincture  of  guaiacum  and  turpentine 
that  have  been  exposed  to  the  air  may  be  used  instead  of  ether. 
This  test  for  blood  is  fallacious,  as  almost  any  carbohydrate,  bile, 


136  ANALYSIS   OF   STOMACH   CONTENTS. 

or  saliva  will  produce  the  same  color  in  the  total  absence  of 
blood. 

The  guaiacum  test,  which  was  originally  proposed  by  Almen 
and  Van  Deen,  becomes  more  reliable  when  executed  by  an  im- 
proved method  suggested  by  H.  Weber.  A  considerable  quantity 
of  the  filtrate  is  extracted  or  mixed  with  water;  glacial  acetic  acid, 
to  the  amount  of  one-third  of  the  entire  quantity  of  water  and  fil- 
trate mixture,  must  be  added. 

Of  this  acid  extract  about  ten  c.c.  are  poured  off  after  settling; 
then  ten  drops  of  tincture  of  guaiacum  and  twenty  to  thirty  drops  of 
turpentine  are  added.  If  blood  is  present,  the  mixture  becomes 
violet-blue ;  in  case  blood  is  absent,  the  color  will  be  red-brown.  The 
blue  coloring-matter  that  indicates  blood  can  be  extracted  by  shak- 
ing the  mixture  with  chloroform.  Coffee-ground  vomit  will  not 
permit  of  the  correct  finding  of  blood  with  either  of  the  two  preced- 
ing tests. 

This  kind  of  vomit  may  have  to  be  differentiated  from  genuine 
tea  or  coffee  vomit,  or  from  bile,  by  Gmelin's  test.  In  this  form  of 
vomit  the  corpuscles  are  disintegrated  and  the  hemoglobin  trans- 
formed into  insoluble  hematin.  Still,  there  are  two  ways  left  to 
diagnose  the  blood  present,  if  any:  first,  the  formation  of  crystals 
of  hemin,  and,  secondly,  the  demonstration  of  the  presence  of  iron. 

1 .  Preparation  of  hemin  crystals :  Three  to  four  drops  of  the  thick 
sediment  is  mixed  on  a  glass  slide  with  a  little  common  salt,  then  one 
to  two  drops  of  glacial  acetic  acid  are  added,  and  the  mixture  care- 
fully heated  over  a  small  flame  of  a  spirit-lamp  or  a  Bunsen  burner 
until  bubbles  begin  to  form.  If  blood  is  present,  on  examining  the 
preparation  with  the  microscope  reddish-brown,  oblong  cr}^stals 
of  hemin  hydrochlorate  will  be  recognized;  their  color,  form,  and 
occurrence  are  characteristic.  This  test  may  fail  in  cases  where  blood 
is  present. 

2.  Demonstration  of  the  presence  of  iron:  Naturally,  the  patient 
whose  stomach  contents  are  to  be  examined  must  not  have  been 
taking  iron  in  any  form,  nor  any  raw  meats. 

Demonstration  of  the  Presence  of  Iron  in  the  Stomach  Con- 
tents or  in  Vomited  Matter, — In  case  one  is  dealing  with  coffee- 
ground  material  this  test  may  become  necessary.  Some  of  the  black 
sediment  is  placed  in  a  porcelain  dish,  and  a  few  crystals  of  potassi- 
um chlorate  and  two  to  three  drops  of  strong  hydrochloric  acid  are 
added.     On  heating  over  a  flame  and  adding  a  few  drops  of  a  five 


FRAGMENTS   OF   MUCOSA,    ETC.,    IN   GASTRIC   CONTENTS.  1 37 

per  cent,  solution  of  potassium  ferrocyanid,  4KCN,  Fe(CN)2  -f  H2O, 
Prussian  blue  will  be  formed.  Boas  and  Sidney  Martin  consider 
this  a  very  delicate  test.  The  Prussian  blue,  upon  the  occurrence  of 
which  this  test  depends,  is  a  complex  cyanid  of  iron,  4Fe(CN)3. 
3i^e(CN)3. 

Spectroscopic  Examination  of  Stomach  Contents  for  Blood. 
— A  spectroscopic  examination  is  possible  when  the  red  blood-cor- 
puscles have  become  dissolved,  and  the  filtrate  of  gastric  contents 
contains  oxyhemoglobin.  The  compound  of  oxygen  with  hemo- 
globin is  distinguished  by  two  absorption  bands  in  the  spectrum, 
which  occur  between  the  Fraunhofer  lines  D  and  E  in  the  yellow 
and  green.  If  after  the  recognition  of  these  lines  a  reducing  agent 
is  added  to  the  solution  of  oxyhemoglobin, — for  instance,  if  it  is 
shaken  with  ammonium  sulphid, — the  two  bands  observed  before 
fuse  into  a  single  broad  band,  occupying  the  space  between  the  two 
distinct  and  separate  bands,  or  move  beyond  D  toward  the  red  of 
the  spectrum.  (Compare  Eichhorst,  loc.  cit.,  p.  523;  also  Richard 
C.  Cabot,  "Clinical  Examination  of  the  Blood,"  Wni.  Wood  &  Co., 
Publishers,  New  York,  1897,  and  von  Jaksch,  loc.  cit.) 

Examination  of  Portions  of  Mucosa  or  Tissue  Found  in  the 
Wash-water  and  Vomited  Matter. — In  the  wash-water  from 
almost  every  stomach,  also  in  the  samples  of  test-meals  gained  by 
the  Ewald  expression  method,  and  in  vomited  matter,  small  portions 
of  the  superficial  mucosa  of  the  stomach  can  frequently  be  found  on 
careful  searching.  Stimulated  by  reading  the  accompanying  liter- 
ature; particularly  the  work  of  Hayem,  Boas,  Einhorn,  and  Cohn- 
heim,  we  have  during  the  last  three  years  made  a  study  of  such  tiny 
bits  of  mucosa. 

To  detect  them  more  easily,  the  stomach  is  best  washed  in  the 
morning,  before  breakfast,  with  500  c.c.  of  warm  water,  which  is 
poured  into  a  shallow  papier-mache  or  hard-rubber  dish,  the  bottom 
of  which  is  colored  white  and  black  like  a  checker-board;  on  this 
background  the  tiny  bits  of  tissue  from  the  mucosa,  or  from  any 
neoplasm  that  may  be  in  the  stomach,  can  be  more  easily  recognized. 
These  particles  are  usually  of  a  reddish  color;  they  may  seem  at 
times  colorless,  so  that  in  a  glass  or  pitcher  they  may  be  overlooked, 
while  on  the  dark,  flat  dish  they  are  quite  apparent.  These  frag- 
ments come  from  very  superficial  erosions,  which  are  possibly  caused 
by  very  slight  local  congestions  or  by  traumatism  (Ewald,  loc.  cit.). 

It  is  conceivable  that  the  contractions  of  the  muscularis  of  the 


138  ANALYSIS    OF    STOMACH    CONTENTS. 

stomacli  may,  if  sufficiently  powerful,  effect  an  arrest  of  the  flow  of 
circulation  in  the  folds  and  cause  intense  congestion  of  the  veins 
and  capillaries,  which  may  give  rise  to  small  hemorrhages  into  the 
mucosa.  These  hemorrhagic  areas  are  very  poorly  nourished  by 
the  blood-current,  and  may  eventually  succumb  to  the  autodigestive 
action  of  the  gastric  juice;  other  gastric  contractions  then  loosen, 
and  cast  off  these  tiny  spots  of  necrosis  (Hartung,  loc.  cit.). 

According  to  Virchow  {loc.  cit.),  circulatory  derangements  of  the 
larger  vessels  of  the  stomach, — the  acute  and  chronic  gastritis  espe- 
cially,— if  accompanied  with  vomiting  and  colicky  contractions,  are 
the  cause  of  ulcers  and  erosions.  Small  erosions  represent  only 
the  superficial  stratum  of  the  mucosa,  generally  only  the  vestibule 
or  alveolus  and  the  first  third  of  the  gland-ducts;  the  entire  lower 
half  of  the  mucous  membrane  is  rarely  cast  off  (Gerhardt,  loc.  cit.). 
The  gland-duct  remaining  shows  nothing  pathological.  At  the  sides 
and  edges  of  the  sequestrated  portion  the  glands  become  longer,  and 
the  first  ones  that  are  intact  usually  curve  themselves  over  the  defect, 
partly  covering  it.  Recovery  takes  place  by  the  simple  after- 
growth of  the  remaining  portions  of  the  glands. 

In  three  stomachs  which  were  taken  immediately  after  death 
(not  later  than  two  hours  after),  we  observed  what  was  undoubtedly 
a  superficial  epithelial  sequestrum  resting  loosely  upon  the  mucous 
membrane  in  many  places  of  what  we  had  every  reason  to  believe 
was  a  perfectly  normal  stomach.  The  autodigestion  in  this  case  had 
been  prevented  by  pouring  ninety  per  cent,  alcohol  into  the  organ 
about  fifteen  minutes  after  death.  In  places,  portions  of  mucosa 
half  as  large  as  a  lentil-seed  could  be  dislodged  by  a  gentle  stream 
of  water  from  a  wash-bottle.  The  erosions  included  the  inner  third 
of  the  gland-duct  proper  ("inneres  Schaltstiick"  of  Stohr),  and  it 
seems  that  even  before  they  were  dislodged  the  process  of  repair 
had  already  begun;  for  underneath  small  areas  of  necrosed  super- 
ficial epithelium  that  were  lifted  from  the  true  glandular  stratum 
by  a  thin  layer  of  lymph  containing  few  red  blood-corpuscles, 
cell  proliferation  was  going  on  in  the  parietal  or  oxyntic  cells,  and  in 
the  cylindrical  cells  of  the  adjoining  intact  epithelium  formation  of 
mitosis  and  karyokinetic  figures  were  evident  in  picrocarmin  and 
eosin  stains  of  these  sequestrations  of  mucosa.  The  presence  of 
mitosis  in  an  apparently  healthy  stomach  somewhat  weakens  the 
assumption  (Ivubarsch)  that  this  is  a  valuable  sign  of  carcinoma. 

It  seems  possible  that  a  process  of  exfoliation  is  constantly  going 


ETIOLOGY   OF*   EROSIONS.  1 39 

on  in  the  lining  membrane  of  the  gastro-intestinal  tract,  just  as  in 
the  epidermis.  It  is  not  conceivable  that  the  constant  and  con- 
tinuous impact  and  friction  of  the  ingesta  should  go  on  daily  without 
causing  necrosis  of  epithelium  in  places.  If  we  should  hold  the  nor- 
mal acid  chyme  in  the  palm  of  our  hands  for  three  or  four  hours 
three  times  or  more  every  day,  we  would  very  soon  notice  dermatitis 
and  exfoliations  of  the  epidermis. 

In  the  digestive  tract  (for  it  occurs  all  along  the  small  intestine) 
this  exfoliation  goes  deeper  than  in  our  hands  because  of  immediate 
autodigestion  of  the  exfoliated  spot.  Although  we  have  examined 
fifty  human  stomachs  with  especial  regard  for  this  phenomenon, 
we  have  failed  to  detect  evidence  of  this  process  in  minute  areas  in 
but  four  cases,  and  in  these  the  examination  was  limited  to  a  very 
small  portion  of  the  stomach. 

Even  in  stomachs  obtained  within  one  hour  after  death,  and 
preserved  by  pouring  alcohol  or  solutions  of  formalin  into  the  organ, 
these  erosions  can  be  seen  in  places.  We  generally  request  a  strip 
which  begins  in  the  esophagus,  runs  through  the  cardia,  saccus  cgecus, 
entire  greater  curvature,  and  pylorus,  and  has  a  piece  of  duodenum 
attached  to  it.  This  is  hardened,  and  in  many  places  pieces  are 
excised  half  an  inch  apart  and  embedded  in  celloidin,  cut  into  serial 
sections  with  the  revolving  microtome,  stained  in  eosin  and  hema- 
toxylin and  mounted  in  balsam.  In  some  cases  we  sectioned  strips 
running  along  the  lesser  curvature. 

In  this  way  it  was  found  that  most  of  these  erosions  and  exfolia- 
tions occur  in  the  vicinity  of  the  sphincter  antri  pylorici,  about  seven 
to  ten  cm.  from  the  pylorus.  At  this  point  the  muscularis  has  its 
most  powerful  development,  and  the  peristalsis,  and  consequently 
the  impact  of  the  food  with  the  mucosa,  is  most  vigorous;  hence 
the  epithelium  here  has  most  to  suffer  from  friction.  Slight  erosions 
can  be  detected  in  the  lower  part  of  the  esophagus,  where  no  peri- 
stalsis normally  occurs  but  that  accompanying  deglutition.  So  the 
conclusion  seems  justifiable  that  very  tiny  exfoliations  and  erosions 
occur  in  all  stomachs,  and,  in  adult  life,  perhaps  at  all  times.  This 
precludes  the  presumption  that  the  pieces  of  mucosa  are  lesions 
produced  by  the  stomach-tube. 

Boas-  (Joe.  cit.)  thinks  that  coughing  or  defecation  may  cause  the 
dislodgment  of  such  loosened  epithelium.  When  this  process  reaches 
such  an  exaggerated  type  as  described  by  Einhorn  {loc:  cit.,  "Ero- 
sions of  the  Stomach"),  it  is  very  probable  that  the  mucosa  is  made 


140  IvITE^RATURE;   on   EXFOIvIATlONS   AND   EROSIONS.  . 

less  resistant  by  some  well-developed  gastric  disease  (one  of  the 
forms  of  gastritis,  carcinoma,  etc.),  for  his  patients  suffered  from 
pains,  emaciation,  and  weakness. 

Among  the  forty-six  stomachs  examined  by  myself  were  nineteen 
in  which  no  symptoms  referable  to  the  stomach  were  given  during 
life.  The  pieces  varied  from  five  mm.  in  length,  and  nearly  as  wide. 
Binhorn  recommends  intragastric  spraying  of  a  solution  of  i  :  1000 
of  argentic  nitrate  for  the  excessive  exfoliation,  combined  with  intra- 
gastric galvanization,  diet,  and  tonics,  with  a  hygienic  outdoor  life. 


LITERATURE 

ON   EXFOLIATIONS   AND    EROSIONS   OF   GASTRIC   MUCOSA. 

1.  Boas,  "  Diagnostik  u.  Therap.  d.  Magenkrankh.,"  "  Allg.  Th.,"  3d  ed,, 
p.  220. 

2.  Boas,  "  Ueber  Gastritis  Acida,"  "  Wiener  med.  Wochenschr.,"  i-ii,  1895. 

3.  Boas,  "  Beitrag  zur  Symptomatologie  des  chronischen  Magenkatarrhs  und 
der  Atrophic  der  Magenschleimhaiit,"  "  Miinch.  med.  Wochenschr.,"  41  u.  42, 

4.  Cohnheim,  Paul,  "  Die  bedeut.  klein.  Schleimhautstiickchen  f.  d.  Diag- 
nose d.  Magenkrankh.,"  "  Archiv  f.  Verdauungskrankh.,"  Band  I,  S.  274. 

5.  Cramer,  "Ueber  d.  Ablosung  d.  Magenschleimhaut  durch  die  Sondi- 
rung,"  "  MUnch.  med.  Wochenschr.,"  p.  52,  1891. 

6.  Damaschino,  "  Note  sur  un  nouveau  precede  pour  I'etude  de  lesions  de 
I'estomac,"  "Gaz.  med.,"  1880. 

7.  Ebstein,  "  Ueber  die  Losung  eines  Stiickes  d.  Pylorusschleimhaut  mit  d. 
Magensonde,"  "  Berliner  klinische  Wochenschr.,"  1895. 

8.  Ebstein,  "  Beitrage  zur  Lehre  vom  Bau  der  sogenannten  Magenschleim- 
driisen,"  "  Schultze's  Archiv,"  Band  vi,  p.  530. 

9.  Einhorn,  "  Clinical  Observations  on  Erosions  of  the  Stomach  and  Their 
Treatment,"  "  N.  Y.  Medical  Record,"  June  23,  1894. 

10.  Einhorn,  "State  of  the  Gastric  Mucosa  in  Secretory  Disorders  of  the 
Stomach,"  "  N.  Y.  Medical  Record,"  June  27,  1896. 

11.  Einhorn,  "Zur  Achylia  Gastrica,"  "Archiv  f.  Verdauungskrankh.," 
Band  i.  Heft  2. 

12.  Ewald,  "  Klinik  d.  Verdauungskrankheiten,"  3d  ed.,  p.  191. 

13.  Ewald,  "  Ein  Fall  chronischer  Sekretionsuntuchtigkeit  des  Magens" 
(Anadenia  ventriculi  ?),  "Das  Benzonapthol,"  "  Berl.  klinische  Wochen- 
schr.," 26  u.  27,  1892. 

14.  Ewald,  "  Ein  Fall  v.  Atrophia  d.  Magenschleimhaut  mit  Verlust  d.  HCl 
Sekretion,  Ulcus  carcinomatosum  duodenale,"  "Berl.  klinische  Wochen- 
schr.," 1886. 

15.  Fenwick,  "Ueber  den  Zusammenhang  einiger  krankhafter  Zustande  des 
Magens  mit  anderen  Organerkrankungen,"  "  Virch.  Archiv,"  Band  118,  xii. 

16.  Gerhardt,  D.,"  Virch.  Archiv,"  Band  cxxvii,  p.  85. 

17.  Hammerschlag,  "Zur  Kenntniss  des  Magencarcinoms,"  "Wiener 
klinische  Rundschau,"  23,  1895. 

18.  Hartung,  O.,  "  Deutsche  med.  Wochenschr.,"  No.  38,  p.  847,  1890. 


LITERATURE   ON   EROSIONS.  I41 

19.  Hayem,  "Gastritis  Parenchymatosa,"  "  Allg.  Wien.  med.  Zeitung," 
1894,  pp.  2-17. 

20.  Hayem,  "  Resume  de  I'Anatomie  Pathologique  de  la  Gastrite  Cliron- 
ique,"  "  Gaz.  Hebdom.,"  pp.  33,  34,  1892. 

21.  Jaworski  u.  Korcynski,  "  Ueber  einige  bisher  wenig  beriicksichtigte 
klinische  und  anatomische  Erscheinungen  im  Verlaufe  des  sogenannten 
Magenkatarrhs,"  "  Archiv  f.  klinische  Med.,"  47,  p.  578. 

22.  Klemperer,  "  Ueber  die  Dyspepsie  der  Phthisiker,"  "  Berlin,  klinische 
Wochenschr.,"  11,  1889. 

23.  Korcynski  u.  Jaworski,  "  Klinische  Befunde  bei  Ulcus  u.  Carcinoma 
Ventriculi,"  etc.,  "Deutsche  med.  Wochenschr.,"  pp.  47-49,  1886. 

24.  Kupffer,  "Epithel  u.  Driisen  d.  menschlichen  Magens,"  Miinchen,  1883. 

25.  Langerhans,  "  Virch.  Archiv,"  Band  cxxiv,  p.  373. 

26.  Meyer,  "  Zur  Kenntniss  der  sogenannten  Magenatrophie,"  "  Zeitschr. 
f.  klinische  Med.,"  Band  xvi,  p.  366. 

27.  Rosenheim,  "Ueber  atrophische  Processe  an  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  u.  als  selbstandige  Erkrankung,"  "Berliner 
klinische  Wochenschr.,"  51,  1881. 

28.  Sachs,  "Zur  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zustan- 
den,"  "Archiv  f.  exp.  Pharm.  u.  Pathol.,"  Band  xxiv,  1888. 

29.  Schmidt,  "  Ein  Fall  von  Magenschleimhautatrophie  nebst  Bemerkungen 
liber  die  sogenannte  schleimige  Degeneration  der  Drijsenzellen  des  Magens," 
"Deutsche  med.  Wochenschr.,"  19,  1895. 

30.  Schmidt,  "  Fortgesetzte  Untersuchungen  iiber  die  Secretion  des  Magen- 
schleims,"  "Deutsche  med.  Wochenschr.,"  Vereinsbeilage,  xiii,  1895. 

31.  Schmidt,  Adolf,  "  Untersuch.  tiber  menschl.  Magenepithel,  normal  u. 
pathol.,"  "  Virchow's  Archiv,"  Band  143,  xix. 

32.  Stintzing,  "  Zum  feineren  Bau  u.  zur  Physiologie  d.  Magenschleimhaut," 
"Miinchener  med.  Wochenschr.,"  46,  1889. 

33.  Stohr,  "Zur  Kenntniss  des  feineren  Baues  der  menschlichen  Magen- 
schleimhaut," "  Schultz's  Archiv,"  Band  xx,  p.  221. 

34.  Virchow,  R.,  "Virch.  Archiv,"  Band  v,  p.  363. 

35.  Hemmeter,  J.  C,  "  Zur  Histologie  d.  Magendriisen  b.  d.  Hyperaciditat," 
"Archiv  f.  Verdauungskrankh.,"  Heft  3,  1898. 


CHAPTER  XIV. 


THE  DIAGNOSTIC  SIGNIFICANCE  OF  FRAGMENTS  OF 
GASTRIC  MUCOSA. 

One  of  the  first  to  utilize  these  fragments  for  diagnostic  purposes 
was  Boas,  who  attributed  great  importance  to  this  way  of  finding 
out  the  real  state  of  the  mucosa.  He  held  that  in  certain  condi- 
tions of  suppressed  secretion  the  differential  diagnosis  between  a 
possible  neurosis  and  a  genuine  gastritis  with  glandular  atrophy 


142  SIGNIFICANCE   OF   FRAGMENTS   OF   MUCOSA. 

was  only  possible  by  examination  of  such  pieces  of  mucosa.  Rosen- 
heim {loc.  cit.),  Boas  (loc.  cit.),  and  Julius  Friedenwald  ("Medical 
News,"  June  22,  1895)  emphasize  the  value  of  qualitative  and  quan- 
titative testing  of  rennin  zymogen  to  differentiate  between  chronic 
gastritis  with  glandular  atrophy  and  carcinoma  on  the  one  hand, 
and  nervous  dyspepsia  and  secondary  gastritis  on  the  other.     How- 


FiG.  19.— Fragment  of  Mucosa  showing  a  Normal  Condition  of  Glands;  very  slight 
round-celled  infiltration.  The  piece  became  detached  above  the  level  at  which  the  oxyntic 
cells  are  found.     X  600. 


ever,  Ewald  {loc.  cit.)  and  also  Einhorn  {loc.  cit.)  have  asserted  that 
absolute  deficiency  of  rennin  zymogen  is  not  pathognomonic  of 
atrophy ;  therefore  it  would  indeed  seem  as  if  a  certain  diagnosis  could 
only  be  made  by  a  small  piece  of  mucosa. 

Is  there  any  clue  which  can  be  derived  from  these  pieces  regard- 
ing the  state  of  the  mucosa  in  the  secretory  disorders  ?  This  we  will 
try  to  answer  in  the  following.     Hayem,  to  whom  we  are  indebted 


HISTOLOGY   OF   THE   FRAGMENTS.  I43 

for  the  best  histological  investigations  of  the  gastric  mucosa,  em- 
phasizes that  the  individual  elements  of  the  mucosa,  gland-ducts, 
superficial  epithelium,  and  interstitial  tissue  can  become  diseased 
in  a  variety  of  ways;  the  various  portions  of  the  stomach,  fundus, 
pylorus,  and  cardia,  may  exhibit  different  affections;  and,  finally, 
the  mucosa  may  at  different  parts  show  different  phases  of  disease. 
He  distinguishes  a  parenchymatous  and  an  interstitial  gastritis. 
First,  the  parenchymatous : 

1.  Gastrite  parenchymateuse  hyperpeptique  chloro-organique. 
Under  this  he  has  two  sub-classes:  (a)  "D'emblee" — dyspeptic 
distress  coming  on  at  once — in  the  first  stage  of  digestion,  (b)  "Tar- 
dive"— dyspeptic  distress  coming  on  in  later  stages — in  one  and 
one-half  to  two  hours.  Under  this  hyperpeptic  parenchymatous 
gastritis,  Hayem  means,  clinically,  a  hyperpepsia  with  hyperacidity 
and,  anatomically,  degeneration  of  the  principal  central  or  chief 
cells,  with  proliferation  of  the  parietal,  border,  or  oxyntic  cells. 

2.  Gastrite  parenchymateuse  muqueuse  (gastritis  mucipara),  by 
which  he  means  a  mucous  degeneration,  a  process  taking  place 
principally  in  the  vestibules  to  the  gland-ducts  (which  are  lined 
with  columnar  epithelium)  and  corresponds  to  the  Schleimkatarrh 
of  most  German  writers.  This  is  associated  with  hypopepsia  and 
subacidity, 

3.  Gastrite  parenchymateuse  atrophique,  which  signifies,  anatom- 
ically, the  total  atrophy  of  the  glands  without  interstitial  processes, 
and,  clinically,  anacidity  or  achylia.  The  interstitial  forms  he 
separates  into  two  classes: 

(a)  Those  in  which  the  round-cell  infiltration; 

(b)  Those  in  which  the  sclerosis,  i.  e.,  connective-tissue  prolifera- 
tion, predominates. 

These  processes  are  described  as  occurring  purely  as  such,  or 
mixed  with  forms  of  parenchymatous  gastritis,  and  as  leading  to 
sub-  or  anacidity.  In  order  to  bring  our  results  in  critical  considera- 
tion with  those  of  Einhorn  {loc.  cit.),  we  have  adopted  his  classifica- 
tion of  the  anatomical  conditions  found  in  these  fragments.  There 
is,  however,  one  objection  that  can  be  urged  against  it,  and  that 
is  the  apparent  fact  that  he  has  based  his  system  upon  conditions 
of  the  gland-tubes  and  interglandular  tissue  exclusive^,  and  men- 
tions the  state  of  the  cells  only  once  in  six  types  described.  We 
shall  therefore  supplement  his  categories  by  adding  the  state  and 
condition  of  the  vestibular  or  alveolar  columnar  cells   (Vorraum- 


144 


SIGNIFICANCE    OP   FRAGMENTS    OF    MUCOSA. 


zellen),  and  the  condition  and  numerical  relations  of  the  chief  cen- 
tral or  ferment  cells  (Hauptzellen),  and  the  parietal,  border,  or 
oxyntic  cells  (Belegzellen) : 

I.  Normal. — The  gland-ducts  and  interglandular  tissue  exist  in 
normal  proportions.  The  columnar  epithelium  of  the  surface  and 
of  vestibule  is  normal,  with  scattered  cells  showing  at  their  free 
ends  slight  mucoid  metamorphosis.     Average  number  of  parietal 


Fig.  20. — Hypertrophy  and  Proliferation  of  Glandular  Elements. — {From  a  case  of  per- 
sistent hyperacidity — specimen  found  in  the  eye  of  the  tube  after  drawing  test-meal.)     X  500. 


or  oxyntic  cells  in  six  ducts  which  were  sectioned  very  nearly  down 
the  center  =  22-40  (see  Fig.  ig). 

2.  Connective-tissue  Excess. — Proliferation  of  connective  tissue 
around  the  glands — glands  and  epithelial  cells  as  in  normal  condition. 

3.  Proliferation  of  Glands. — Under  this  class  we  have  in  the  ex- 
amination of  nineteen  cases  been  impressed  with  the  probability 
that  there  are  three  types  of  this  condition: 


HISTOLOGICAL   CONDITIONS   PRESENT. 


145 


Type  a. — Increase  of  gland-tubules,  but  normal  number  of  border 
cells.  In  this  sub-type  there  is  a  proliferation  of  gland-tubules. 
Under  the  same  field  of  microscope  there  will  be  more  of  them  than 
under  normal  conditions,  since  they  are  much  closer  to  each  other, 
but  the  number  of  central  and  oxyntic  cells  are  from  18-42,  or  the 
same  as  under  the  normal  condition. 


Fig.  21. — Atrophy  and  Vacuolization  of  Glandular  Elements— Mucoid  Degeneration 
OF  Peptic  Cells— Increase  of  Interstitial  Connective  Tissue— Small  Round-celled 
Infiltration.— (FroOT  a  case  of  chronic  alcoholic  gastritis.  Found  in  the  wash-water.) 
X  500. 


Type  h. — Increase  of  oxyntic  or  parietal  cells  with  normal  number 
of  gland-ducts.  Here  there  seems  to  be  no  proliferation  of  the 
gland-ducts.  The  connective  tissue  and  the  ducts  bear  the  same 
relation-  as  in  class  i,  but  the  anilin-staining  oxyntic  cells  may  be 
so  increased  that  they  lie  in  juxtaposition,  giving  the  whole  duct  the 
appearance  of  a  peptic  duct  of  the  dog;  the  number  may  reach 
seventv  in  one  duct.     The  oxvntic  cells  are  increased  in  size. 


146  SIGNIFICANCE   OF   FRAGMENTS   OF   MUCOSA. 

Type  c. — Increase  of  the  number  of  ducts  in  which  the  number 
of  oxyntic  cells  appear  normal  in  size  and  number,  and,  in  the  same 
fragment  or  section,  portions  of  mucosa  in  which  the  ducts  are  not 
augmented,  but  the  oxyntic  cells  are  increased  in  number  and  size; 
this  third  type  is  a  combination  of  types  a  and  b.  When  there  are 
many  oxyntic  cells  above  the  normal,  the  entire  gland-duct  assumes 
a  tortuous  or  elongated  shape.  It  seldom  extends  down  into  the 
mucosa  in  the  same  plane ;  therefore  it  is  very  rare  that  a  section  will 
strike  down  the  middle  of  a  duct.  Generally  the  counts  in  sixteen  ducts 
struck  fairly  along  the  central  canaliculus  are  taken  as  an  average. 

4.  Incipient  Atrophy. — To  the  same  field,  under  the  micrometer, 
there  are  fewer  glands  present  than  normally ;  they  appear  shrunken 
and  smaller,  at  the  same  time  the  spaces  between  the  glands  are 
larger  than  normal  owing  to  an  increased  connective-tissue  forma- 
tion; the  latter  is  thickly  invaded,  as  a  rule,  with  small  round-cell 
infiltration.     The  next  type  is — 

5.  A  trophy. — In  complete  atrophy  there  are  only  remnants  of  glands 
left,  a  few  degenerated  cells  lying  in  empty  circular  spaces  where 
glands  had  previously  existed;  there  is  also  a  diffuse  round-celled 
infiltration  (see  Fig.  21). 

6.  Vacuolization. — Round  or  ovoid  vacuoles  exist  within  the 
glands  in  large  numbers,  being  the  result  of  mucoid  degeneration 
of  some  of  the  glandular  ceUs;  this  is  generally  associated  with  con- 
nective-tissue proliferation  (see  Fig.  21).  Vacuoles  are  present  in 
the  gland-ceUs  normally,  as  can  be  seen  in  the  drawings  of  Kupher 
and  Stohr.  We  have  also  seen  them  in  both  longitudinal  and  cross- 
section  of  the  gland-tubules,  but  rarely  more  than  two  or  three  to 
the  entire  duct.  It  is  conceivable  that  they  may  be  produced  by 
the  process  of  hardening  and  imbedding.  Some  of  the  fragments 
obtained  from  stomachs  may  show  characteristics  of  two  types. 

Deductions  from  Fifty  Cases. — (Hemmeter,  "Ueber  die  His- 
tologic der  Magendriisen, "  etc.;  Boas,  "Archiv  f.  Verdauungskrank- 
heiten,"  Bd.  iv,  p.  30).  In  fourteen  healthy  persons  the  mucosa 
fragments  were  normal  in  eleven;  proliferation  and  autodigestion 
marked  in  one,  which  showed  also  beginning  small  round-cell  in- 
filtration between  the  ducts ;  connective-tissue  increase  in  one.  In  a 
third  case  the  examination  showed  proliferation  in  one  fragment, 
and  a  normal  condition  in  a  second  found  in  the  same  wash-water. 

In  twenty-two  cases  of  hyperacidity  the  fragments  of  gastric 
mucosa  found  were  apparently  normal  in  four. 


HISTOLOGICAL    CONDITIONS    PRESENT.  147 

Atrophy  of  gland-tubules  and  connective-tissue  increase,  so  that 
there  were  fewer  glands, — but  in  these  few  there  were  contained  a 
larger  number  of  oxyntic  cells  than  normal, — in  two  cases. 

Proliferation  of  gland-ducts,  with  apparently  normal  oxyntic 
cells,  in  eight  cases. 

Proliferation  of  oxyntic  cells,  generally  without  marked  increase 
in  the  gland-tubules,  in  eight  cases. 

In  fourteen  cases  of  anacidity  or  suhacidity  the  fragment  was 
apparently  normal  in  four  cases. 

Proliferation  of  glands,  with  marked  small  round-cell  infiltration, 
was  found  once. 

Atrophy  in  some  form  was  found  in  the  fragments  from  the  nine 
remaining  cases. 

In  establishing  the  classification  of  euchlorhydria  and  hyperchlorhydria  we 
could  not  be  guided  exclusively  by  the  amount  of  free  HCl  found  after  the 
double  test-meal. 

Thus,  a  young,  vigorous  farmer,  aged  twenty-five,  who  never  had  any  disease, 
showed  on  repeated  examination  an  amount  of  free  HCl  equal  to  60°,  with  a 
total  acidity  of  80°.  Ordinarily,  judging  simply  from  the  analysis,  such  a  case 
would  be  diagnosed  as  hyperacidity,  according  to  the  principles  defined  in 
the  chapter  on  the  normal  amount  of  HCl ;  however,  these  cases  can  be  diag- 
nosed justly  and  accurately  when  considered  together  with  concomitant  signs 
and  symptoms  only.  Although  this  case  had  the  large  amount  of  free  HCl, 
there  was  no  starch  indigestion,  no  erythrodextrin,  no  pyrosis  ;  there  were  no 
symptoms  referable  to  the  stomach  at  all  ;^the  man  was  in  perfect  health. 

Another  case,  a  neurasthenic  female  had  been  suffering  intensely  from  hy- 
peracidity and  occasional  gastroxynsis,  and  the  amount  of  free  HCl  was  never 
over  30°,  This  case  showed  hypermotility  ;  the  stomach,  as  a  rule,  was  empty 
twenty-five  minutes  after  an  Ewald  test-meal ;  with  our  intragastric  rubber  bag, 
in  connection  with  the  kymograph,  she  showed  very  frequent  and  sudden 
gastric  peristalsis  of  unusual  tonicity. 

Summary  of  results  from  examination  of  fragments  of  mucosa  in 

fifty  cases: 

/Perfectly  normal  in  eleven. 

(  (a)  Glandular  proliferations  in  one  ;   {b)  normal 
Fourteen  healthy  persons  :       (      in  one.   These  fragments  {a  and  b)  were  found 

/      in  same  wash-water. 
\  Connective-tissue  increase  in  two. 
Normal  in  four. 
Atrophy  in  two. 

Twenty-two  cases  of  Hyper-    )  Proliferation  of  gland-ducts,  but  normal  oxyntic 
acidity  :  ]      cells  in  eight. 

Proliferation  or  hypertrophy  of  oxyntic  cells  in 
eight. 

■c       .  r  A        -A-^  {  Normal  in  four. 

Fourteen  cases  of  Anacidity      ti     ir      ^-         c    ^      j    ■ 

or  Subacidity  :  )  P'-ol'^^'-ation  of  glands  in  one.        . 

^  (  Atrophy  in  nine. 


148  SIGNIFICANCE    OF   FRAGMENTS    OF    MUCOSA. 

In  general  we  find  proliferation,  therefore,  present  in  two-thirds 
of  these  cases  of  hyperacidity,  and  atrophy  in  three-quarters  of 
these  cases  of  anacidity  or  subacidity.  Einhorn  {loc.  cit.)  does  not 
give  any  results  from  examination  of  perfectly  healthy  individuals, 
as  his  cases  of  euchlorhydria  seem  to  be  in  patients. 

Of  the  twelve  hyperacid  cases,  three  were  normal,  or  very  nearly 
so,  six  showed  proliferation,  and  three  showed  connective-tissue 
proliferation.  In  his  cases  of  anacidity,  or,  rather,  what  he  calls 
achylia  gastrica,  of  which  there  were  seven  cases,  there  was  atrophy 
three  times,  marked  vacuolization  once,  proliferation  once,  and 
normal  condition  twice. 

On  the  whole,  judging  from  Kinhorn's  results,  Cohnheim's,  Hay- 
em's,  and  our  own,  the  conclusions  seem  justifiable  that  proliferation 
of  glandular  elements  is  present  in  from  one-half  to  two-thirds  of  the 
cases  of  hyperacidity;  and  atrophy  is  present  in  from  one-half  to 
two-thirds  of  the  cases  of  anacidity. 

Adolf  Schmidt  ("Virchow's  Archiv,"  Bd.  cxLiii,  S.  478)  asserts 
that  the  epithelium  of  the  surface  of  the  stomach  is  preserved  better 
than  the  gland-cells  in  inflammatory  conditions  of  the  mucosa. 
This,  he  says,  is  particularly  so  in  chronic  gastritis,  which  forms 
island-like  foci  in  stomachs  otherwise  not  much  changed.  Our 
experience,  and  that  of  W.  D.  Booker,  is  not  in  accordance  with  this 
observation  (see  Pathology  of  Simple,  Acute,  and  Chronic  Gastritis 
in  the  clinical  portion  of  this  work).  Although  we  preserved  the 
stomachs  by  injecting  them  immediately  after  death  (within  twenty 
minutes)  with  alcohol,  also  with  formalin  and  sublimate,  so  that 
autodigestion  was  at  once  checked,  our  sections  showed  generally 
a  more  serious  destruction  of  the  surface  epithelium  than  of  the  gland- 
cells.  At  times  both  are  so  much  altered  that  it  is  impossible  to 
say  which  is  most  or  least  affected.  It  seems,  in  chronic  gastritis, 
that  new  epithelium  will  be  re-formed  quite  rapidly  where  the  old 
has  been  lost  or  destroyed. 

In  cases  of  suspected  malignant  neoplasm  fragments  of  the  growth 
are  occasionally  found  and  are  of  importance  in  the  diagnosis.  In 
carcinoma  of  the  cardia  or  the  esophagus  they  are  most  frequently 
found  in  the  lower  or  side  opening  of  the  tube,  as  it  must  pass  through 
or  over  the  growth  on  its  way  into  the  stomach.  But  even  in  malig- 
nant growths  of  other  parts  of  the  stomach,  patient  searching  in  the 
sediment  of  the  wash-water  will  sometimes  reward  the  clinician  by 
the  discovery  of  tumor  fragments.     Of  the  first  wash-water  in  the 


HISTOLOGICAL   CONDITIONS   PRESENT.  149 

morning,  about  500  c.c.  should  be  permitted  to  settle  twelve  hours 
in  a  conical  glass  such  as  is  used  for  the  settling  of  solid  urinary- 
constituents,  or  the  gastric  contents  should  be  brought  to  settle  out 
minute  particles  by  use  of  the  centrifuge.  The  sediment  should  be 
examined  under  a  low  power  (about  fifty  diameters) .  The  centrifuge 
is  preferable,  as  long  standing  of  the  fluid  causes  putrefaction. 

Once  we  made  the  diagnosis  of  carcinoma  when  no  tumor  was 
evident,  from  repeatedly  finding  involuntary  muscle-fibers  when  no 
meat  had  been  eaten  for  six  days  after  thorough  lavage.  Four 
months  later,  at  the  autopsy,  it  proved  to  be  a  broad,  flat  carcinoma 
of  the  posterior  wall.  The  method  of  recognition  of  neoplastic  frag- 
ments will  be  fully  considered  in  the  chapter  on  Carcinoma. 

The  drawing  of  a  longitudinal  section  of  the  secreting  gland- 
tubules,  showing  beautifully  the  well-preserved  cylindrical  epithe- 
lium of  the  gastric  surface  and  well-differentiated  oxyntic  and  chief 
cells,  was  made  from  several  sections  of  a  piece  of  mucosa  that 
was  torn  loose  by  the  stomach-tube,  inserted  by  a  medical  student 
who  tried  to  aspirate,  by  means  of  the  pump,  a  meal  that  had  dis- 
agreed with  him.  The  tearing  off  must  have  occurred  in  an  instant, 
as  there  were  no  signs  of  inflammation  in  the  sections.  The  sections 
were  stained  in  a  variety  of  ways,  principally  in  the  eosin,  hema- 
toxylin, Golgi,  and  Bismarck-brown  stains.  The  minute  communi- 
cations of  the  oxyntic  or  parietal  cells  with  the  central  duct  are  best 
brought  out  by  the  Golgi  method  (see  frontispiece). 

The  drawings  of  fragments  found  in  the  wash-water,  illustrating 
glandular  proliferation,  with  glands  closely  packed  and  connective 
tissue  diminished,  and  of  glandular  atrophy,  mucoid  degeneration 
vacuolization,  and  small-cell  infiltration,  are  all  explained  by  the 
text  accompanying  the  illustrations.  We  have  seen  that  histological 
changes  approaching  or  actually  representing  pathological  states 
may  be  going  on  in  perfectly  healthy  stomachs.  Furthermore,  the 
stomachs  of  diseased  patients  may,  on  serial  sections,  show  a  different 
pathological  state  at  different  places  of  the  mucosa.  Therefore  it 
must  be  borne  in  mind  that,  although  the  findings  in  hyperacidity 
and  anacidity  appear  to  be  in  some  relation  to  the  disease,  this  kind 
of  investigation  must  not  be  relied  upon  as  representing  in  a  given 
fragment  the  condition  of  the  entire  mucosa.  It  represents  the 
state  of  the  location  whence  it  sequestrated ;  that  location  not  being 
accurately  known,  generalizations  must  be  made  with  caution. 

It  should  be  emphasized  that  the  most  important  conditions  in 


I50  CHEJMISTRY    OF    GASTRIC    CONTENTS." 

these  fragments  are  not  the  number  of  gland-ducts  and  the  state  of 
the  connective  tissue,  but  the  relative  number  of  oxyntic  or  border 
and  chief  or  central  cells.  A  fragment  may  show  a  normal  or  sub- 
normal number  of  gland-ducts,  and  at  the  same  time  these  may 
contain  an  abnormally  large  number  of  cells. 


CHAPTER  XV. 

THE  CHEMISTRY  OF  GASTRIC  DIGESTION. 

Occurrence  of  Secretions  in  the  Empty  Stomach. — Stimulations  to  Secre- 
tions of  Gastric  Juice. — Significance  of  Foam. — Preparation  of 
Gastric  Contents. — Quantitative  Analysis. — Methods. — Standard 
or  Normal  Solutions. — Indicators. — Titration. — Apparatus.^ 

Most  authors  are  of  the  opinion  that  no  secretion  is  contained  in  the 
empty  stomach.  Schreiber  ("Arch.f.  exper.  Pathol,  u.  Phar.,"  Bd. 
XXIV,  S.  365;  also,  "Deutsche  med.  Wochenschr.,"  1894,  Nos.  18 
to  21),  however,  concludes  that  a  secretion  is  found  also  in  the  empty 
stomach ;  that  is,  he  denies  a  continuous  secretion  or  gastro-succorrhea 
as  a  disease  sui  generis,  and  claims  to  be  able  to  obtain  60  c.c.  of  a 
secretion  possessing  good  digestive  power  from  a  jejune,  or  fasting, 
stomach. 

Pick  ("Prager  med.  Wochenschr.,"  1889,  No.  18),  who  obtained 
similar  results,  believed  that  the  secretion  was  set  up  by  the  stimula- 
tion of  the  tube.  Rosin  ("Deutsche  med.  Wochenschr.,"  1888,  No. 
47),  A.  Hoffmann  ("Berliner  klin.  Wochenschr.,"  1889,  No.  12), 
and  Martins  ("Deutsche  med.  Wochenschr.,"  1894,  p.  638)  have 
also  obtained  a  digestive  secretion  from  the  fasting  stomach. 

Although  there  may  be  found  50  to  60  c.c.  of  a  secretion  possessing 
digestive  powers  in  the  empty,  normal  stomachs  of  perfectly  healthy 

*  The  section  on  quantitative  chemical  analysis  of  gastric  contents  and  the  chapters  on 
the  condition  of  the  blood  and  urine  in  gastric  diseases  and  on  the  gases  of  the  stomach 
have  been  written  by  my  former  associate,  Dr.  Edward  L.  Whitney,  whose  experience 
as  demonstrator  of  clinical  pathology  has  admirably  fitted  him  for  the  concise  and  clear 
account  of  this  department.  It  gives  me  pleasure  to  express  my  thanks  to  him  for  his 
assistance. — (J.  C.  II.) 


GASTRIC   SECRETION   IN   THE   EMPTY   STOMACH.  151 

individuals,  this    does    not    prove    that  a   continued  secretion  ex- 
ists  normally    (Riegel,    "Deutsche    med.    AVochenschr.,"    1893,    p. 
735).     Leo  ("Krankheiten  d.  Bauchorgane,"  p.  54)  considers  this 
digestive  secretion  a  residuum  of  the  last  previous  meal,  and  seems 
to  have   shown  conclusively  that  such  a  residuum  is  constantly 
present  in  the  stomachs  of  infants  after  a  night's  sleep  (see  Leo, 
"Berliner   khn.    Wochenschr.,"    1888,   No.   49).     For  the    practical 
objects  of  diagnosis  he  concludes  that  a  secretion  of  50  to  60  c.c.  of 
digestive  fluid  found  in  a  fasting  organ  must  not  be  considered 
pathological.     Only  when  the  amount  gained  reaches   100  to  300 
c.c.  does  it  indicate  hypersecretion,  which  is  often  associated  with 
hyperacidity   (Reichmann,   "Berliner  klin.  Wochenschr.,"   1887,  S. 
12;  Bouveret  [loc.  cit.];  Debove,   and  Remond,   "Les  Maladies  de 
I'Estomac").     Riegel  and  Reichmann  do  not  distinguish  sufftciently 
between  so-called  continuous  secretion  of  gastric  juice  with  a  stom- 
ach of  normal  capacity  and  normal  exit  to  the  duodenum  and  con- 
tinuous   secretion   which   appears   as   a   concomitant   symptom   of 
gastrectasia  with  probable  pyloric  stenosis.     Einhorn  asserts  that, 
with   more   accurate   differentiation   between   these   states,    it   will 
probably  be  found  that  the  normal  stomach  in  a  fasting  condition 
contains  very  little,  if  any,  secretion.     We  have  studied  a  number 
of  cases  whose  stomachs  were  of  natural  size  and  where  there  was 
no   disturbance,   but  which  contained  this   secretion  early  in  the 
morning  before  breakfast. 

J.  Schreiber  ("Deutsche  med.  Wochenschr.,"  1894,  No.  53)  has 
experimented  upon  two  healthy  persons,  before  any  food  had  been 
taken,  and  found  gastric  juice  with  hydrochloric  acid  in  both.  The 
amount  of  secretion  thus  obtained  varied  from  10  to  22  c.c.  Martins 
("Deutsche  med.  Wochenschr.,"  1894,  No.  32)  and  Huber  ("Kor- 
respondenzblatt  f.  Schweizer  Aerzte,"  1894,  No.  49)  confirm  Schrei- 
ber's  results.  According  to  Ewald,  who  sums  up  the  literature  (in 
Lubarsch  and  Ostertag's  "Ergebnisse  d.  spez.  Pathologic,"  Bd.  in, 
S.  27)  and  gives  his  own  observations  in  a  large  number  of  cases, 
this  problem  is  represented  in  the  following  manner :  In  many  indi- 
viduals small  quantities  of  a  digestive  secretion  containing  free 
hydrochloric  acid  can  be  obtained  from  the  fasting,  or  jejune,  stom- 
ach. Sometimes  it  is  mixed  with  bile,  coloring  matter,  and  duodenal 
contents.  But  he  claims  that  the  stimulation  to  this  secretion  has 
been  furnished  by  swallowed  saliva  (Martins),  remnants  of  food, 
pharyngeal  secretion,  etc.,  and  that  the  state  of  things  lies  between 


152  MEANS    OF    OBTAINING   GASTRIC    SECRETION. 

a  normal  and  an  abnormal  one,  and  that  there  is  no  diseased  condi- 
tion of  the  gastric  mucosa. 

In  the  case  of  typical  gastrosuccorrhea,  however,  there  is  a  much 
increased  irritability  of  the  mucosa,  giving  rise  eventually  to  a  pro- 
fuse secretion,  which,  when  found  in  empty  stomachs,  is  quantita- 
tively more  considerable  than  that  found  in  normal  jejune  stomachs. 
Huber  compares  it  to  a  slow,  gradual  dying  away  of  secretory  irrita- 
bility ("Abklingen  des  Sekretionsreizes")  that  has  been  set  up  by 
the  ingesta  and  seems  to  linger  after  they  have  passed  into  the 
duodenum. 

In  order  to  obtain  gastric  secretion  a  variety  of  methods  have 
been  suggested: 

By  chemical  stimulation,  according  to  Leube's  method,  which 
consists  in  allowing  50  c.c.  of  a  three  per  cent,  solution  of  sodium 
bicarbonate  to  flow  into  the  stomach.  After  twelve  minutes  this  is 
washed  out  again,  and  should  be  found  neutral.  By  thermic  stimu- 
lation, according  to  Jaworski's  method,  consisting  of  the  introduc- 
tion of  100  c.c.  of  ice-water  and  washing  it  out  again  after  ten  min- 
utes, when  it  should  contain  acid  and  pepsin.  These  methods,  if 
successful  at  all,  bring  out  the  gastric  juice  in  a  most  diluted  state, 
and,  therefore,  give  no  adequate  means  of  determining  the  secretion 
by  chemical  analysis.  It  has  been  claimed  by  Einhorn  ("New  York 
Medical  Record,"  November  9,  1889)  and  Allen  A.  Jones  {ibid.,  1891) 
in  this  country,  and  Hoffmann  ("Berliner  klin.  Wochenschr.,"  1889, 
No.  13),  Ewald  {loc.  cit.),  and  Ziemssen,  in  Germany,  that  the  gastric 
secretion,  as  evinced  by  the  amount  of  hydrochloric  acid,  could  be 
increased  by  faradic  or  galvanic  stimulation.  While  we  have  our 
doubts  about  this  matter,  we  do  not  wish  to  imply  that  electricity 
is  not  a  very  valuable  therapeutic  agent  in  the  treatment  of  secretory 
diseases;  we  could  not,  in  fact,  dispense  with  it  as  an  auxiliary  to 
treatment.  In  our  opinion,  the  influence  of  electricity  on  secretion 
is  doubtful. 

As  a  means  of  obtaining  gastric  secretion,  this  method  is  certainly 
not  available.  The  normal  secretions  are  best  obtained  by  the 
natural  stimulation  of  one  of  the  test-meals,  as  stated  in  a  previous 
chapter. 

Mathieu  and  Remond  ("Societe  de  Biolog.,"  1890)  have  pub- 
lished a  method  of  determining  the  total  quantity  of  stomach  con- 
tents by  finding  out  the  acidity  of  the  undiluted  contents  as  much 
as  can  be  drawn ;  then  that  of  the  contents  as  much  as  can  be  gained 


PREPARATION    OP    GASTRIC    CONTENTS.  153 

by  washing  out  the  stomach  with  a  known  quantity  of  water,  and 
from  this  the  acidity  of  the  total  amount  of  contents  that  were 
originally  in  the  stomach  are  calculated.  Strauss  ("Therapeutische 
Monatshefte,"  Marz,  1895)  has  simplified  this  procedure,  but  for 
the  practitioner  it  is  sufficient  to  know  the  amount  gained  by  the 
simple  methods  of  drawing  the  contents  by  expression  or  aspiration. 
Concerning  the  recognition  of  proteid  and  carbohydrate  indigestion 
from  the  food-remnants,  it  should  be  added  that  this  is  much  facili- 
tated by  the  double  test-meal  used  at  the  University  of  Maryland 

Hospital. 

In  gastrectasias  presence  of  foam  indicates  gas-fermentation.  Gas 
may  be  found  even  in  presence  of  normal  or  supernormal  amount  of 
hydrochloric  acid,  since  F.  Kuhn  ("Zeitschr.  f.  klin.  Med.,"  Bd. 
XXI,  and  "Deutsche  med.  Wochenschr.,"  1892,  No.  49)  has  demon- 
strated that  the  hydrochloric  acid  of  gastric  juice  has  no  detrimental 
effect  on  large  amounts  of  yeast.  Whenever  there  is  stagnation  of 
gastric  contents  this  gas-formation  can  occur. 

After  the  contents  of  the  stomach  are  withdrawn,  they  must  be 
prepared  for  and  submitted  to  chemical  examination.  The  contents 
may  be  beaten  up  thoroughly  to  make  a  homogeneous  mixture,  and 
the  chemical  examinations  conducted  on  this  mixture ;  or  this  mixture 
may  be  filtered  and  the  clear  filtrate  subjected  to  analysis.  The 
former  method  gives  more  accurate  results,  with  slightly  higher 
acidity,  than  the  latter  method,  which  has  the  advantage,  however, 
of  allowing  better  observation  of  color  changes  in  the  solution  during 
titration. 

Before  entering  upon  a  discussion  of  the  chemical  methods  as 
applied  to  the  gastric  juice,  a  short  description  of  the  methods, 
solutions,  and  apparatus  required  in  quantitative  analysis  will  be 
given. 

The  solutions  required  can  be  made  up,  and,  if  preserved  from 
the  influence  of  light  and  air,  kept  indefinitely. 

The  methods  used  in  quantitative  chemical  analysis  may  be 
divided  into  two  great  classes:  Gravimetric  and  Volumetric.  The 
gravimetric  methods  consist  in  the  isolation  of  the  substance  or 
one  of  its  compounds,  which  is  weighed.  The  isolation  of  substances 
in  a  pure  state  often  requires  long  training  in  chemical  methods, 
and  if  only  a  small  amount  of  the  substance  in  question  is  present  it 
may  be  very  difficult  to  separate  a  weighable  amount.  .Many  sub- 
stances can  not  be  separated  from  mixtures  without  losing  at  the 


154  STANDARD    SOLUTIONS. 

same  time  their  relation  to  other  substances  in  the  same  solution. 
The  great  objection  to  the  gravimetric  methods,  however,  is  the 
large  amount  of  costly  apparatus  necessary,  and  the  length  of  time 
needed  for  the  manipulations. 

The  volumetric  methods  are  more  easily  performed.  In  these  the 
quantity  of  the  substance  under  examination  is  ascertained  by  a 
calculation  based  upon  a  measured  quantity  of  a  solution  of  a  known 
strength  required  to  perform  a  certain  reaction  with  it. 

These  solutions,  called  standard  solutions,  are  of  two  kinds — 
normal  solutions  and  empirical  solutions. 

A  normal  solution  is  one  which  contains  in  a  liter  that  quantity  of 
the  active  reagent  expressed  in  grams  which  equals  the  sum  of  the 
atomic  weights  of  the  constitutents  that  combine  with  one  atom  of 
hydrogen.  Thus  the  normal  solution  of  HCl  is  a  liter  of  distilled 
water  containing  36.5  grams  c.p.  HCl  (H  =:  i,  CI  =  35.5)  in  solution. 

Decinormal  solutions,  Nio,  are  one-tenth  the  strength  of  normal 
solutions. 

Centinormal  solutions,  Njoo,  are  one-hundredth  the  strength  of 
normal  solutions. 

Empirical  solutions  are  those  which  do  not  contain  an  exact  atomic 
proportion  of  the  reagent,  but  are  made  up  of  such  strength  that 
one  c.c.  is  equivalent  to  some  definite  weight  of  the  substance  sought. 

Residual  titration,  or  back  titration,  consists  in  treating  the  sub- 
stance under  examination  with  standard  solution  in  excess  of  that 
known  to  be  required;  the  excess  is  then  ascertained  by  residual 
titration  with  another  standard  solution. 

In  general,  titration  results  in  the  formation  of  a  compound  that 
can  readily  be  distinguished  by  its  properties  from  those  substances 
present  in  either  solution. 

1.  It  may  form  a  precipitate. 

2.  It  may  cause  the  complete  solution  of  some  precipitate. 

3.  A  slight  excess  of  either  reagent  may  produce  some  visible 
change  in  some  constituent  of  the  solution,  or  a  change  in  some 
substance  added  for  the  purpose  (indicators). 

4.  The  indicator  in  some  cases  can  not  be  added  to  the  solution, 
but  from  time  to  time  a  few  drops  of  the  solution  are  added  to  the 
indicator  on  a  watch-glass  at  the  side. 

Of  the  above,  the  normal  solution  is  the  most  used,  the  empirical 
solution  being  only  of  limited  application. 

It  would  seem  a  simple  matter  to  make  up  a  standard  solution 


DEJCINORMAI.    SOLUTIONS.  1 55 

which  would  be  perfectly  accurate,  but  in  practice  the  problem  re- 
quires experience.  Absolutely  pure  chemicals  are  not  easily  ob- 
tained, and  such  as  are  easily  obtained,  unmixed  with  other  mineral 
substances,  contain  a  variable  amount  of  water,  and  are,  moreover, 
exposed  to  more  or  less  danger  of  contamination  from  the  impurities 
of  the  air.  The  following  methods  of  obtaining  a  tenth-normal 
solution  are  recommended  as  a  basis  for  the  preparation  of  other 
solutions : 

I .  Pure,  dry  oxalic  acid  is  obtained,  and  the  crystals  that  show  no 
sign  of  efflorescence  selected.  From  the  formula,  C2H2O4  -f  2H2O, 
it  is  seen  that  the  molecular  weight  is  126,  and  as  it  is  a  dibasic 
acid  the  normal  solution  would  contain  one-half  of  this  (63  gm.) 
dissolved  in  distilled  water  and  made  up  to  one  liter  at  a  tempera- 
ture of  15°  C.  As  a  tenth-normal  (Nm)  solution  is  required,  one- 
tenth  of  this,  or  6.3  gm.,  are  made  up  to  a  liter  as  before,  and  used 
to  correct  the  solutions  employed  in  analysis.  It  must  be  noticed 
that  oxalic  acid  in  dilute  solution  soon  decomposes ;  it  is,  therefore, 
to  be  freshly  prepared  as  required. 

To  prepare  an  equivalent  solution  of  caustic  soda  (decinormal 
NaOH)  about  five  gm.  of  caustic  soda  are  dissolved  in  about  900  c.c. 
of  distilled  water  and  well  mixed.  To  this  there  is  added  lime- 
water  or  baryta-water,  Ca(0H)2  or  Ba(0H)2,  as  long  as  a  precipitate 
forms,  to  get  rid  of  carbonates  or  sulphates.  The  solution  is  allowed 
to  stand  until  the  impurities  have  settled.  Twenty-five  c.c.  of  the 
solution  are  then  measured  with  a  pipette  into  a  clean  flask  or  beaker 
and  titrated  with  the  above  solution  of  oxalic  acid,  using  a  few 
drops  of  phenolphthalein  as  an  indicator,  until  the  red  color  of  the 
solution  just  disappears.  The  solution  is  then  diluted  to  the  strength 
of  a  decinormal  solution. 

As  an  illustration  of  the  method  of  ascertaining  the  amount  of 
dilution  necessary  to  make  the  two  solutions  exactly  equivalent,  we 
will  suppose  that  the  25  c.c.  of  caustic  soda  solution  required  28.3 
c.c.  of  the  oxalic  acid  solution  to  cause  the  red  color  to  disappear. 
If  25  c.c.  of  the  caustic  soda  solution  neutralize  28.3  c.c.  of  the  acid 
solution,  then  the  amount  of  caustic  soda  solution  necessary  to 
neutralize  1000  c.c.  of  the  acid  solution  will  be  found  by  the  following 
proportion : 

28.3  :  25  :  :  looo  :  (X)  X  =  883.4 

X  =  amount  of  caustic  soda  solution  necessary  for  looo  Ni„  NaOH, 
Dilute  883.4  c.c.  of  the  caustic  soda  to  looo  c.c.  with  distilled  water. 


156  INDICATORS. 

After  diluting  the  solution  it  should  be  again  titrated  to  insure 
its  accuracy,  and,  if  properly  standardized,  it  will  change  from  red 
to  colorless,  and  vice  versa,  by  the  addition  of  a  drop  or  two  of  the 
acid  or  alkaline  solutions,  respectively.  The  titration  should  be 
conducted  as  rapidly  as  possible  to  avoid  the  error  produced  by 
absorption  of  CO2  froin  the  air,  and  the  solutions  kept  in  well-stop- 
pered bottles  for  the  same  reason. 

2.  About  eight  gm.  of  pure,  dry  sodium  carbonate  are  heated  in  a 
platinum  crucible  for  ten  minutes  at  a  dull-red  heat,  stirring  occa- 
sionally with  a  platinum  wire.  After  heating,  it  is  powdered  in  a 
warm  mortar  and  allowed  to  cool  in  a  desiccator.  When  cool,  5.3 
gm.  of  the  powder  are  weighed  rapidly,  washed  into  a  flask  with  hot 
distilled  water,  and  made  up  to  a  liter.  This  constitutes  a  decinormal 
solution  of  sodium  carbonate. 

A  decinormal  solution  of  sulphuric  acid  is  prepared  in  the  following 
manner:  About  three  c.c.  of  the  pure  acid,  of  a  specific  gravity  of 
1.840,  is  made  up  to  about  900  c.c. 

The  approximate  solution  is  standardized  against  the  sodium 
carbonate  solution  prepared  as  above,  using  a  drop  or  two  of  a  o.i 
per  cent,  solution  of  methyl-orange  as  an  indicator.  Twenty-five 
c.c.  of  the  acid  solution  is  titrated  with  the  decinormal  sodium 
carbonate  until  the  red  color  shown  by  this  indicator  in  acid  solution 
turns  to  a  light  yellow.  The  correction  of  the  approximate  solution 
is  made  from  a  proportion  upon  exactly  the  same  principle  as  in  the 
former  case  (Xo.  i). 

To  correct  this  decinormal  solution  of  sulphuric  acid  for  very 
accurate  work,  the  following  method  is  recommended :  One  hundred 
c.c.  of  the  decinormal  solution  of  sulphuric  acid  is  alkalinized  with  a 
strong  solution  of  pure  ammonia  (ammonium  hydrate).  The  solu- 
tion is  evaporated  on  the  water-bath,  heated  to  105°  C.  in  hot-air 
bath,  cooled,  and  weighed.  The  amount  of  sulphuric  acid  is  calcu- 
lated from  the  amount  of  ammonium  sulphate  formed. 

Indicators. — An  indicator  is  a  substance  used  in  volumetric  analy- 
sis, which  marks,  by  change  of  color  or  some  other  visible  effect,  the 
exact  point  at  which  a  given  reaction  is  complete. 

Generally  the  indicator  is  added  to  the  substance  under  examina- 
tion, but  in  a  few  cases  it  is  used  outside,  a  drop  of  the  solution  being 
brought  in  contact  with  a  drop  of  the  indicator. 

The  particular  uses  of  the  indicators  will  be  more  fully  explained 
in  their  proper  places,  under  the  quantitative  examination  of  the 


APPARATUS.  ^^'^ 


gastric  juice ;  but  the  chief  ones  in  use  in  such  examinations  may  be 

'^IL^r  ormmus,  which  tutns  ted  in  acid  solution  blue  in  an 
JZ.  solution.  It  is  used  in  solution,  and  also  ,n  the  totnt  ot 
test-papers.     (It  is  not  used  when  carbonates  are  present.) 

Phenolphthalein  solution,  a  one  per  cent,  -l^'.on  o  phenol- 
phlhalein  in  alcohol,  colorless  in  acid  solutions,  red  m  alkahne  olu- 
rons      It  is  not  reliable  tor  alkaline  phosphates,  b.carbonates,  or 

Tethyl-orange  solution,  a  c,  per  cent,  solution  of  -thyl-orange 

in  water  turns  red  with  acids,  yellow  with  alkalies.     It  ,s  not  affected 

bTcarlonic  acid,  and  is  valuable  for  titration  ot  alkahne  carbonates. 

'The  other  indicators  and  their  uses  in  anlaysis  of  the  gastr.c  jutce 

will  be  mentioned  later.  . 

Aplaratu.-'rH.  apparatus  needed  for  volumetrtc  work  >s  com 
parativelv  simple-burettes,  measuring-flasks,  measurmg-cylmders 
:rp.pettes.     An  accurate  balance  is  required  in  all  che^-l  -  k 
delicate  to  a  milligram  and  weighing  up  to,  say,  50  g™.     Burettes 
a     glass  tubes  graduated  to  tenths  of  a  c.c.  and  holding  from  .5  to 
To  c  c      They  L  provided  at  the  lower  end  with  a  rubber  tube  and 
Xch-cock,  by  means  of  which  the  amount  of  the  solutton  can  be 
Lcurately  regulated.     The  tube  is  graduated  upon  its  outer  surface 
and  the  amount  of  the  solution  used  can  be  read  off  from  this  gradua 
don      The  simplest  form  of  burette  is  the  one  already  described, 
known  as  Mohr's,  of  which  various  modifications  are  m  use^ 

The  burette  should  be  placed  perfectly  perpendicular,  and  firmly 
fastened.  Fill  by  a  tunnel,  the  stem  resting  against  the  1™"  surface 
of  the  burette  to  avoid  the  formation  of  bubbles.  Always  fill  abov 
1  zero  mark;  gently  tap  the  burette  until  the  bubbles  d.sappe  r 
should  they  be  formed.  Then  run  out  a  small  portion  (or  down  to 
the  zero  mark),  remembering  to  run  out  enough  to  remove  all  air- 
bubbles  from  the  bottom  of  the  burette. 

In  reading  the  results,  always  read  from  the  bottom  ot  the  meniscus 
formed  by  the  rising  of  the  outer  borders  of  the  liquid  along  the  sides 
of  the  burette. 


158  TESTS  FOR  PRESENCE   OF   FREE   ACIDS. 

CHAPTER  XVI. 

CHEMICAL  EXAMINATION  OF  GASTRIC  JUICE. 

Tests    for    Presence    of    Free    Acids. — Tests    for  Free  Hydrochloric 

Acid. — The  Dimethyl-Amido-Azo-Benzol  Test. — The  Resorcin 

Test. — Combined  Hydrochloric  Acid. — Lactic  Acid: 

Formation,  Significance,  Detection. 

Reaction. — The  reaction  of  the  gastric  juice,  obtained  by  means 
of  the  stomach-tube  or  otherwise,  after  the  administration  of  a  test- 
meal,  is  always  acid  in  the  normal  individual.  The  reaction  is  best 
determined  by  dipping  into  the  juice  a  piece  of  very  delicate  blue 
litmus-paper.  In  juice  of  acid  reaction  the  paper  immediately  turns 
red.  Very  rarely  is  the  reaction  alkaline,  this  being  found  only  in  a 
few  cases  of  atrophy  of  the  gastric  mucosa,  occasionally  in  acute 
gastritis,  and  when,  for  some  reason,  a  portion  of  the  intestinal  con- 
tents and  the  alkaline  bile  has  been  forced  through  the  pylorus  in 
sufl&cient  quantit}^  to  neutralize  the  acid  of  the  stomach. 

In  severe  cases  of  gastric  atrophy  the  reaction  is  usually  acid, 
even  in  absence  of  fermentative  changes.  This  is  due  to  the  presence 
of  acid  salts,  such  as  acid  sodium  phosphate  (NaH2P04),  and  of 
traces  of  organic  acids,  which  occur  in  nearly  every  test-meal  in 
quantities  sufficient  to  produce  an  acidity  of  from  six  to  ten  degrees. 

Tests  for  Presence  of  Free  Acids. — A  delicate  test  for  the  pres- 
ence of  free  acids  is  found  in  Congo-red.  This  substance  occurs  as  a 
fine  reddish-brown  powder,  dissolving  readily  in  water  to  form  a 
clear  deep-red  solution,  which  changes  in  the  presence  of  free  acids  to 
a  dark  blue.     It  may  be  used  in  two  ways  as  an  indicator. 

1.  A  solution  is  prepared  by  dissolving  one  gm.  of  the  powder  in 
100  c.c.  of  water,  and  adding  a  drop  to  a  few  c.c.  of  the  gastric  juice. 
If  the  juice  contains  even  a  slight  trace  of  free  hydrochloric  acid, 
or  the  organic  acids  in  slightly  larger  quantities,  the  solution  im- 
mediately turns  a  bright  blue. 

2.  A  test-paper  may  be  prepared  by  soaking  bibulous  paper  in 
the  above  solution  of  the  dye  for  several  hours  and  then  carefully 
drying.  This  paper  is  simply  dipped  into  the  filtrate  or  into  the 
contents  before  filtration,  and  exhibits  the  same  color  reaction  as 


TESTS   FOR   FREE    HYDROCHLORIC    ACID.  1 59 

the  solution  mentioned  above,  and  has  the  additional  advantages  of 
being  more  convenient  and  exhibiting  as  readily  slight  changes  in 
color.  It  has  been  found,  also,  that  when  the  acidity  is  due  to 
organic  acids  and  not  to  free  hydrochloric  acid,  the  color  can  be 
made  to  disappear  by  warming  gently  over  the  open  flame.  If  the 
acidity  is  due  to  hydrochloric  acid,  on  the  contrary,  the  dark-blue 
stain  on  the  paper  changes  to  a  lighter  tint,  but  does  not  disappear 
except  when  strongly  heated. 

It  must  be  emphasized  that  this  color-change  from  red  to  blue 
does  not  occur  in  solutions  of  acid  salts  or  in  the  presence  of  com- 
bined hydrochloric  acid,  and  therefore  indicates  the  presence  of  some 
free  acid — inorganic  or  organic. 

Tests  for  Free  Hydrochloric  Acid. — Many  tests  have  been  pro- 
posed for  free  hydrochloric  acid,  the  following,  given  in  the  order  of 
their  accuracy  and  delicacy,  being  probably  the  most  reliable : 

1.  Dimethyl-amido-azo-benzol 0.02  pro  1000 

2.  Phloroglucin-vanillin, 0.05         " 

3.  Resorcin 0.05         " 

The  Dimethyl-Amido-Azo-Benzol  Test. — This  test,  recently 
introduced  by  Topfer,  is  probably  destined  to  replace  all  others  in 
the  clinical  laboratory,  both  on  account  of  its  simplicity  and  also 
on  account  of  its  ready  application  to  the  direct  quantitative  esti- 
mation of  the  amount  of  free  hydrochloric  acid  in  the  gastric  juice. 
This  indicator  occurs  in  the  form  of  a  brown  powder,  readily  soluble 
in  alcoTiol,  only  slightly  soluble  in  water.  A  few  drops  of  the  alco- 
holic solution,  added  to  a  solution  of  hydrochloric  acid,  turns  a 
bright  cherry-red,  increasing  in  intensity  as  the  strength  of  the  acid 
solution  is  increased.  In  the  absence  of  free  hydrochloric  acid  or 
other  mineral  acid  the  solution  turns  a  bright  lemon-yellow. 

In  actual  practice  a  0.5  per  cent,  solution  of  the  substance  in 
alcohol  is  employed.  A  few  drops  of  this  solution  are  added  to  the 
stomach  contents,  which  need  not  be  filtered  for  this  purpose,  or  to 
the  residue  left  in  the  receptacle  in  which  the  stomach  contents 
were  received.  If  free  hydrochloric  acid  is  present  the  cherry-red 
color  develops  and  spreads  in  beautiful  rings  from  each  drop  of  the 
indicator,  usually  leaving  in  the  center  a  clear,  yellow  area.  In 
case  the  indication  is  doubtful,  the  following  modification  may  be 
employed:  A  small  porcelain  evaporating  dish  (or  white  butter 
plate)  is  thoroughly  rinsed  with  distilled  water  and  dried.     Upon 


l6o  THE    PHLOROGLUCIN-VANILLIN    TEST. 

one  side  of  the  dish  a  few  drops  of  the  filtrate  are  placed,  and  upon 
the  opposite  side  a  single  drop  of  the  indicator.  By  inclining  the 
dish  gently  the  two  solutions  may  be  made  to  mix,  and  at  the  line 
of  junction  the  cherry-red  color  may  be  seen,  the  white  background 
rendering  the  detection  of  the  tint  less  difficult. 

It  has  been  stated  by  Einhorn  and  others  that  this  test  is  liable 
to  mislead  in  cases  in  which  there  is  a  large  amount  of  organic  acidity. 
It  is  true  that  in  the  presence  of  lactic  acid  amounting  to  0.2  per 
cent,  or  more  in  gastric  juice  this  test  yields  a  red  color,  resembling 
that  due  to  inorganic  acids;  but  the  objection  is  more  theoretical 
than  real,  as  the  presence  of  such  an  amount  of  organic  acids  seldom 
occurs  in  the  stomach,  and  in  the  presence  of  proteids,  peptones, 
mucin,  etc.,  still  stronger  solutions  of  the  organic  acids  are  required 
to  produce  the  characteristic  reaction. 

Furthermore,  the  quantitative  estimation  of  organic  acidity,  to  be 
described  presently,  will  show  the  necessity  of  employing  further 
tests  for  the  presence  of  free  hydrochloric  acid,  on  account  of  a 
specially  great  acidity  of  organic  acids,  which  does  not,  as  a  rule, 
occur  in  a  stomach  secreting  a  normal  amount  of  h^^drochloric  acid. 

The  Phloroglucin-vanillin  Test.^The  modification  of  this  test 
proposed  by  Boas  gives  the  most  satisfactory  results.  Two  gm. 
of  phloroglucin  and  one  gm.  of  vanillin  are  dissolved  in  100  gm.  of 
80  per  cent,  alcohol.  The  solution  must  be  kept  in  a  dark-colored, 
well-stoppered  bottle,  as  it  soon  decomposes  when  exposed  to  the 
light.  The  original  Giinzberg  formula  was  composed  of  the  same 
amount  of  the  ingredients  dissolved  in  30  c.c.  of  absolute  alcohol. 
This  solution  still  more  readily  undergoes  decomposition,  and  has 
no  advantages  over  the  above  modification.  The  solution  is  em- 
ployed in  the  following  manner :  Four  or  five  drops  of  the  reagent  are 
mixed  on  a  small  porcelain  dish  or  small  butter  plate  with  an  equal 
amount  of  the  filtered  gastric  juice  or  the  unfiltered  gastric  contents. 
This  is  placed  on  a  water-bath,  kept  just  below  the  boiling  point, 
and  evaporated  slowly.  If  free  hydrochloric  acid  be  present  in  the 
proportion  of  0.05  pro  thousand  or  more,  a  fine  rose  tint  will  develop 
at  the  edge  of  the  drop  where  the  mixture  is  dried. 

The  mixture  may  be  evaporated  over  a  naked  flame  with  the 
same  results,  provided  the  temperature  is  not  raised  above  the 
boiling  point.  If  too  much  heat  is  applied,  a  brown  or  brownish- 
red  color  may  develop,  which  resembles  the  color  produced  where 
free  hydrochloric  acid  is  absent.     The  rose  color  produced  by  this 


RESORCIN    TEST    FOR    FREE    HYDROCHLORIC    ACID.  l6l 

reagent  comes  only  from  free  mineral  acids;  organic  acids,  acid  salts, 
combined  hydrochloric  acid,  peptone,  and  albumose  produce  only  a 
brown  or  yellowish  discoloration. 

The  Resorcin  Test. — The  solution  consists  of  five  gm.  of  resorcin 
(resublimed),  and  three  gm.  of  cane  sugar  dissolved  in  loo  c.c.  of 
94  per  cent,  alcohol.  Six  drops  of  the  filtered  gastric  juice  and  three 
drops  of  the  solution  are  mixed  on  a  porcelain  plate  and  slowly 
evaporated  as  in  the  phloroglucin-vanillin  (Glinzberg)  test.  Care 
here  must  also  be  employed  that  too  much  heat  is  not  applied,  as 
heating  too  strongly  simply  yields  a  brown  or  black  deposit.  If  the 
operations  be  properly  conducted  and  free  hydrochloric  acid  be 
present,  a  fine  vermilion  line  forms  at  the  edge  of  the  drops,  following 
down  the  edge  of  the  solution  as  evaporation  proceeds,  while  the 
color  at  the  periphery  gradually  fades,  disappearing  entirely  after  a 
short  time,  leaving  a  reddish-brown  stain.  This  test  has  the  same 
degree  of  delicacy  as  the  phloroglucin-vanillin  test  and  the  advantage 
of  much  greater  stability,  retaining  its  delicacy  for  months,  while  the 
latter  lasts  onl}''  a  few  weeks. 

Many  other  tests  might  be  mentioned,  some  of  them  much  less 
delicate,  among  them  Tropseolin  oo,  Mohr's  reagent,  methyl-violet, 
and  emerald-green,  but  the  three  described  will  be  found  the  most 
reliable  and  easily  applied. 

Combined  Hydrochloric  Acid. — If  albuminous  bodies  are  treated 
with  a  weak  solution  of  hydrochloric  acid,  it  is  found  that  a  certain 
amount  of  the  hydrochloric  acid  combines  with  them  to  form  com- 
pounds which  do  not  give  the  reactions  of  free  hydrochloric  acid.  In 
other  words,  certain  affinities  of  the  albuminous  substance  must  be 
saturated  before  hydrochloric  acid  appears  in  the  free  state.  In 
the  stomach  the  same  reaction  must  take  place,  probably  to  a  greater 
extent,  due  to  the  more  complicated  chemical  processes  through 
which  these  substances  pass.  This  is  shown  by  the  fact  that  even 
after  a  simple  test-meal  a  certain  amount  of  time  elapses  before  the 
presence  of  free  hydrochloric  acid  can  be  demonstrated.  In  the 
Ewald  meal  from  twenty  to  forty  minutes  elapse  before  free  hydro- 
chloric acid  can  be  demonstrated  in  the  normal  individual,  while  in 
the  more  complex  meals  considerably  more  time  is  required.  This 
form  of  hydrochloric  acid  is  important,  inasmuch  as  it  constitutes  a 
part  of  the  physiological  hydrochloric  acid,  and  stomach  digestion 
will  proceed  in  a  fairly  normal  manner,  if  enough  hydrochloric  acid 
is  secreted  to  saturate  these  affinities,  while  not  enough  is  secreted 


1 62  LACTIC   ACID  FORMATION,    ETC. 

to  form  the  excess  or  reserve  supply  called  free  hydrochloric  acid. 
It  is  evident,  therefore,  that  if  free  hydrochloric  acid  be  present,  all 
these  affinities  must  be  saturated,  while  in  its  absence  some  hydro- 
chloric acid,  enough  to  more  or  less  saturate  these  affinities,  may 
have  been  secreted.  The  entire  absence  of  hydrochloric  acid,  both 
free  and  combined,  if  more  than  temporary,  is  a  serious  condition, 
indicating  an  atrophy  of  the  gastric  mucosa,  a  severe  gastric  catarrh, 
achylia  gastrica,  or,  perhaps,  cancer.  From  these  considerations  it 
will  be  seen  how  important  the  determination  of  the  combined 
hydrochloric  acid  is,  in  all  conditions  of  anacidity.  The  estimation 
and  quantitative  determination  of  the  combined  hydrochloric  acid 
will  be  deferred  to  the  paragraphs  devoted  to  the  quantitative  deter- 
mination of  hydrochloric  acid. 

The  amount  of  pure  hydrochloric  acid  necessary  to  combine  with 
I  GO  gm.  (or  ICO  c.c.)  of  the  various  food-stuffs  will  be  given  in  the 
chapter  on  the  Therapy  of  HCl. 

Lactic  Acid :  Formation,  Significance,  Detection. — It  was 
formerly  supposed  that  lactic  acid  was  secreted  by  the  stomach, 
but  by  the  more  accurate  investigations  of  later  years  it  has  been 
shown  beyond  doubt  that  lactic  acid. in  the  gastric  contents  is  either 
introduced  as  such  in  the  food  or  is  the  product  of  abnormal  fer- 
mentative changes  in  the  food  after  ingestion. 

Lactic  acid  may  be  introduced  in  food  either  as  sarcolactic  acid 
from  meat  or  fermentation  lactic  acid  found  in  bread  and  other 
starchy  foods.  Lactic  acid  may  be  formed  after  the  food  is  ingested, 
in  cases  of  carcinoma  of  the  stomach"  and  probably  also  in  small 
amounts  in  other  conditions,  of  subacidity  or  anacidity  associated 
with  deficient  motility. 

In  the  great  majority  of  cases  of  carcinoma  of  the  stomach  lactic 
acid  is  present  in  considerable  amounts,  except  in  those  cases  in 
which  the  motility  is  not  impaired.  In  such  cases  only  a  small  amount 
of  lactic  acid  can  usually  be  demonstrated;  sometimes  it  is  absent. 
There  are  cases  of  carcinoma  of  the  fundus  or  body  of  the  stomach 
in  which  the  motility  is  so  good  that  at  the  end  of  one  hour  no  re- 
mains of  the  test-meal  can  be  regained. 

Traces  of  lactic  acid  can  usually  be  detected  for  some  time  after 
the  administration  of  the  Ewald  breakfast  or  similar  meals,  though 
at  the  height  of  digestion  the  usual  tests  are  negative,  due  either  to 
the  absorption  of  the  lactic  acid,  or  the  interference  of  free  hydro- 
chloric acid,  or  the  products  of  digestion  with  the  delicacy  of  the 


RECOGNITION    OF    IvACTIC    ACID.  1 63 

tests.*  In  cases  in  which  it  is  desirable  to  prove  the  formation  of 
lactic  acid  within  the  stomach,  it  is  necessary  to  employ  some  meal 
which  is  entirely  free  from  lactic  acid. 

Such  a  meal  has  been  proposed  by  Boas,  consisting  of  oatmeal- 
gruel  to  which  only  a  little  salt  has  been  added.  The  stomach  is 
washed  out  on  the  evening  preceding  the  administration  of  the  meal 
until  no  food-particles  can  be  found,  the  gruel  given  in  the  morning, 
and  the  contents  removed  one  hour  after. 

Only  rarely,  under  such  conditions,  is  any  notable  amount  of 
lactic  acid  to  be  demonstrated  except  in  cases  of  carcinoma  of  the 
stomach.  The  easiest  clinical  test  for  the  presence  of  lactic  acid  is 
that  of  Uffelmann.  Ten  c.c.  of  a  four  per  cent,  solution  of  carbolic 
acid  are  mixed  with  twenty  c.c.  of  water,  and  a  drop  of  a  strong 
solution  of  ferric  chlorid  added.  A  beautiful  amethyst-blue  color  is 
produced,  which  turns  a  canary-yellow  when  treated  with  a  solution 
of  lactic  acid  or  gastric  juice  containing  lactic  acid.  The  delicacy 
of  this  test  is  interfered  with  by  the  presence  of  free  hydrochloric 
acid  and  peptones.  Glucose,  acid  phosphates,  citric  acid,  and  alcohol 
give  a  reaction  resembling  that  of  lactic  acid,  butyric  acid  giving  a 
much  lighter  tint.  In  case  of  doubt,  a  modification  that  has  given 
good  results  is  the  following:  Five  or  ten  c.c.  of  the  filtered  gastric 
juice  are  treated  with  ten  times  their  volume  of  ether,  free  from 
alcohol,  and  then  shaken  in  a  stoppered  separating  funnel  for 'fifteen 
or  twenty  minutes  and  allowed  to  stand  till  the  layers  have  separated. 
The  ethereal  solution  is  allowed  to  evaporate,  the  residue  dissolved 
in  five  or  ten  c.c.  of  water,  and  the  solution  tested  for  lactic  acid  as 
above.  While  this  test  is  not  a  very  delicate  one,  lactic  acid,  when 
present  in  considerable  amounts,  gives  a  more  decided  reaction  than 
any  of  the  substances  mentioned  as  having  a  similar  reaction,  and 
it  is  a  good  test  for  clinical  purposes. 

Boas'  method  is  to  be  employed  in  doubtful  cases.  This  method 
is  based  upon  the  fact  that  when  lactic  acid  is  treated  with  strong 
oxidizing  agents,  formic  acid  and  acetic  aldehyd  are  formed: 

CgHgOa  =:  CHjCOH  -j-  HCOOH. 
Acetic  aldehyd  may  be  easily  recognized  by  its  action  on  Nessler's 


*Sticker  ("  Miinch.  med.  Wochenschr  ,"  1896,  No.  26)  has  shown  that  passage  of 
carbohydrates  through  the  mouth  is  followed,  without  exception,  by  thie  formation  of 
more  or  less  lactic  acid. 


164  DETECTION   OF   LACTIC   ACID. 

reagent,  or  upon  an  alkaline  solution  of  iodin  in  iodid  of  potassium. 
Nessler's  reagent  is  prepared  in  the  following  manner: 

One  hundred  c.c.  of  a  four  per  cent,  solution  of  iodid  of  potassium 
are  warmed,  and  while  warm  treated  with  iodid  of  mercun,'  until  a 
small  amount  remains  undissolved.  After  cooling,  40  c.c.  of  water 
are  added.  Two  parts  of  this  solution  are  then  treated  with  three 
parts  of  a  strong  solution  of  caustic  potash;  any  precipitate  which 
may  form  is  filtered  off  and  the  reagent  kept  in  a  well-stoppered 
bottle. 

The  solution  of  iodin  is  prepared  by  mixing  a  solution  of  iodin  in 
iodid  of  potassium  with  caustic  potash  or  potassium  carbonate. 

Method. — The  filtered  gastric  juice  is  tested  for  the  presence  of 
free  acids  as  above,  and,  if  present,  10  or  20  c.c.  are  treated  with  an 
excess  of  barium  carbonate.  If  no  free  acids  are  present,  this  is  not 
necessar}^  The  solution  is  now  evaporated  to  a  syrup  on  the  water- 
bath  to  drive  off  the  fatty  acids.  The  syrup  is  treated  with  a  few 
drops  of  phosphoric  acid  and  brought  to  a  boiling  point  to  expel 
carbon  dioxid.  After  cooling  it  is  extracted  with  100  c.c.  of  ether 
free  from  alcohol  by  shaking  for  half  an  hour.  After  standing  for  a 
short  time  to  allow  separation  to  take  place,  the  ethereal  layer  is 
drawn  off  and  evaporated  (avoiding  a  flame),  the  residue  taken  up 
in  45  c.c.  of  water,  shaken,  and  filtered.  The  filtrate  is  treated  in  an 
Hrlenmever  flask  with  5  c.c.  of  strong  sulphuric  acid  and  as  much 
black  oxid  of  manganese  as  will  lie  on  the  point  of  a  knife-blade. 
The  flask  is  closed  with  a  perforated  stopper,  in  which  is  placed  a 
bent  glass  tube,  the  long  arm  passing  into  a  cylinder  filled  with  10 
or  15  c.c.  of  Nessler's  reagent  or  alkaline  iodin  solution  prepared  as 
described.  Carefully  heat  the  flask,  and  if  lactic  acid  is  present  alde- 
hyd  will  distil  over,  forming  aldehyd  mercury,  yellowish  red  in  color, 
if  Nessler's  reagent  is  used,  and  yellowish  crystals  of  iodoform,  which 
may  be  recognized  by  their  odor,  if  the  alkaline  solution  of  iodin  is 
employed. 

Butyric  acid  can  usually  be  determined  by  its  odor  alone,  which 
is  that  of  rancid  butter.  In  case  of  doubt,  10  c.c.  of  the  gastric 
juice  are  extracted  with  50  c.c.  of  ether,  the  ethereal  solution  evapo- 
rated, and  the  residue  taken  up  with  water.  The  odor  is  more  evident 
in  this  concentrated  aqueous  solution.  A  small  amount  of  calcium 
chlorid  causes  the  separation  of  an  oily  layer  of  butyric  acid;  strong 
mineral  acids  also  separate  the  oily  layer  or  drops  of  the  acid. 

Acetic  acid  mav  also  be  detected  bv  its  odor. 


QUANTITATIVE    ANALYSIS    OF    THE    STOMACH   ACIDS.  1 65 

Ten  c.c.  of  the  gastric  juice  are  extracted  with  ether,  the  ether 
evaporated,  the  residue  taken  up  with  a  small  amount  of  water, 
accurately  neutralized  with  caustic  soda  solution,  and  mixed  with 
a  few  drops  of  a  very  dilute  solution  of  ferric  chlorid.  In  the  presence 
of  acetic  acid  this  gives  a  dark-red  color. 

The  ethereal  residue  after  evaporation  is  taken  up  with  a  small 
amount  of  strong  sulphuric  acid  and  alcohol.  If  acetic  acid  is 
present,  the  fragrant  odor  of  ethyl  acetate  is  easily  detected. 

Fatty  acids  do  not  occur  normally  in  the  stomach  contents.  Bu- 
tyric acid  may  be  formed  when  a  large  amount  of  milk  or  carbo- 
hydrates have  been  ingested,  usually  associated  with  an  excess  of 
lactic  acid.  It  has  been  shown  also  that  butyric  acid  can  be  formed 
from  lactic  acid. 

Acetic  acid,  on  the  contrary,  is  a  product  of  alcohol,  and  may  be 
formed  from  alcohol  ingested  or  from  alcohol  produced  by  the  action 
of  yeast  upon  the  sugar  contained  in  the  stomach  contents.  Hence 
it  follows  that  it  is  necessarv'  to  exclude  alcoholism  before  significance 
is  attached  to  the  presence  of  acetic  acid  in  the  stomach  contents. 
If,  in  the  case  of  acetic  acid,  alcoholism  be  excluded,  and,  in  the  case 
of  butyric  acid,  the  ingestion  of  butter  or  fats  in  general  be  excluded, 
the  presence  of  these  acids  has  the  same  significance  as  the  occurrence 
of  lactic  acid — viz.,  stenosis  of  the  pylorus  with  dilatation  and  fer- 
mentation. 


CHAPTER  XVII. 
QUANTITATIVE  ANALYSIS  OF  THE  STOMACH  ACIDS. 

Numerous  methods  have  been  devised  for  the  estimation  of  the 
amount  of  free  hydrochloric  acid  present  in  the  gastric  juice.  The 
most  convenient  method  of  estimation  for  clinical  purposes  is  that 
of  Topfer,  which  at  the  same  time  estimates  the  acidity  due  to 
organic  acids  and  acid  salts,  and  that  due  to  the  combined  hydro- 
chloric acid. 

Topfer's  Method. — Three  indicators  are  used  in  this  method: 

1.  A  0.5  per  cent,  alcoholic  solution  of  dimethyl-amido-azo-benzol. 

2.  A  one  per  cent,  aqueous  solution  of  alizarin  (alizarin  mono- 
sulphonate  of  sodium). 


i66  topfer's  method. 

3.  A  one  per  cent,  alcoholic  solution  of  phenolphthalein. 

1.  As  has  been  mentioned  under  the  head  of  tests  for  free  hydro- 
chloric acid,  dimethyl-amido-azo-benzol  reacts  to  very  faint  traces  of 
mineral  acids,  particularly  hydrochloric,  but  to  organic  acids  only 
when  present  in  very  large  amounts,  and  not  at  all  to  combined 
hydrochloric  acid  or  acid  salts.  It  will  be  seen  that  by  this  indicator 
we  can  easily  find  the  amount  of  free  hydrochloric  acid.  Topfer's 
method  gives  results  as  reliable  as  those  of  the  improved  Sjoqvist's 
or  Braun's  method,  according  to  Paul  Hari  ("Arch.  f.  Verdauungs- 
krankheiten,"  Bd.  11,  S.  332). 

Ten  c.c.  of  the  filtered  gastric  juice  are  measured  into  a  small, 
clean  flask,  and  a  few  drops  of  dimethyl-amido-azo-benzol  added. 
The  solution  turns  a  bright  red  in  the  presence  of  free  hydrochloric 
acid.  The  solution  is  now  titrated  with  a  decinormal  solution  of 
caustic  soda  (prepared  as  above)  until  the  red  color  of  the  solution 
changes  to  a  clear  yellow. 

2.  Into  a  second  beaker  or  flask  ten  c.c.  of  the  gastric  juice  are 
measured,  a  few  drops  of  the  alizarin  solution  added,  and  the  solu- 
tion titrated  with  the  decinormal  solution  of  caustic  soda  until  the 
solution  turns  to  a  clear  violet  color. 

As  this  tint  is  difficult  for  the  unpractised  eye  to  recognize,  Topfer 
recommends  the  following  preliminary  tests: 

(a)  To  five  c.c.  of  distilled  water  add  two  or  three  drops  of  the 
alizarin  solution.     A  clear  yellow  color  results. 

(b)  To  five  c.c.  of  a  one  per  cent,  solution  of  disodium  phosphate 
add  the  alizarin  solution  as  above.  A  reddish  color  with  a  slight 
tinge  of  violet  results. 

(c)  Five  c.c.  of  a  one  per  cent,  solution  of  sodium  carbonate  when 
treated  with  alizarin,  as  above,  give  a  clear  violet  tint,  which  is  the 
tint  to  be  reached  in  the  titration.  Until  the  eye  becomes  accus- 
tomed to  the  reaction,  it  is  well  to  prepare  this  solution  as  a  guide 
in  the  titration. 

3.  To  a  third  portion  (ten  c.c.)  of  the  filtered  gastric  juice  two  or 
three  drops  of  phenolphthalein  solution  are  added  and  the  solution 
titrated  with  the  decinormal  solution  of  caustic  soda.  After  a  cer- 
tain amount  of  the  solution  has  been  added,  a  light-rose  color  de- 
velops, which  is  not,  however,  the  end  of  the  reaction.  It  will  be 
noticed  that  as  the  drop  of  caustic  soda  solution  falls  into  the  solu- 
tion a  dark-red  color  is  produced  at  the  point  of  contact,  fading 
into  rose  color  on  agitation.     The  titration  must  be  carried  on  until 


topfbr's  method.  167 

the  entire  solution  has  reached  this  color  and  no  line  of  separation 
can  be  made  out  on  adding  a  drop  of  the  caustic  soda  solution. 

There  are  two  ways  of  stating  the  result  of  the  titrations.  The 
simplest  method  is  to  state  the  number  of  c.c.  of  the  caustic  soda 
solution  which  would  be  necessary  to  neutralize  100  c.c.  of  the 
gastric  juice  as  that  number  of  degrees  of  acidity.  For  example, 
the  number  of  c.c.  of  the  caustic  soda  solution  necessary  to  neu- 
tralize ten  c.c.  of  the  gastric  juice,  using  dimethyl-amido-azo-benzol 
as  an  indicator,  is  2.3  c.c.  One  hundred  c.c.  would  then  require 
ten  times  that,  the  amount  of  acidity  being  stated  as  23  degrees 
=  23  c.c. 

The  second  method  of  stating  the  results  is  to  give  the  amount 
of  acid  per  thousand  in  terms  of  hydrochloric  acid.  As  each  c.c. 
of  the  solution  of  caustic  soda  will  neutralize  0.00365  gm.  of  pure 
hydrochloric  acid,  the  above  example  would  show  0.8395  gm.  of 
hydrochloric  acid  per  thousand,  or  0.08395  per  cent. 

As  an  example  of  the  calculations  employed  in  Topfer's  method, 
let  us  suppose  that  in  the  titration  (i)  with  dimethyl-amido-azo- 
benzol  as  an  indicator,  3.5  c.c.  of  caustic  soda  solution  were  em- 
ployed, (2)  with  alizarin  4.9  c.c.  of  the  caustic  soda  solution  were 
required,  and  (3)  with  phenolphthalein  7.5  c.c.  of  caustic  soda  solu- 
tion were  required  to  produce  the  proper  tint,  using  in  each  case 
ten  c.c.  of  the  stomach  contents. 

1.  As  dimethyl-amido-azo-benzol  reacts  only  with  free  hydro- 
chloric acid,  the  acidit}^  referable  to  this  is  35  degrees,  or  0.12775 
per  cent. 

2.  Alizarin  shows  the  tint  of  an  alkaline  reaction  when  the  free 
hydrochloric  acid,  organic  acids,  and  acid  salts  have  been  neutral- 
ized, combined  hydrochloric  acid  having  no  effect  upon  it.  Hence 
it  follows  that  by  subtracting  the  amount  of  free  hydrochloric  acid 
from  the  acidity  found  by  alizarin,  the  amount  of  acidity  due  to 
organic  acids  and  acid  salts  will  be  found;  in  this  case  49  —  35  = 
14  degrees,  or  0.05 11  per  cent. 

3.  Phenolphthalein  turns  to  a  dark-red  color  when  all  the  acidities 
of  the  solution  have  been  saturated,  including  the  combined  hydro- 
chloric acid.  The  amount  of  combined  hydrochloric  acid  may  be 
found  by  subtracting  the  acidity  found  by  alizarin  from  that  found 
by  phenolphthalein;  in  this  case  75  —  49  =  26  degrees,  or  0.0949 
per  cent. 

Method  of  Martius  and  Liittke. — Bv  this  method  the  amount 


1 68  METHOD   OF   MARTIUS  AND  LlJTTKK. 

of  physiological  hydrochloric  acid,  the  free  and  combined  hydro- 
chloric acid,  are  found,  as  well  as  the  total  chlorin  of  the  gastric 
juice,  by  determination  of  the  amount  of  chlorin.  The  method  is 
based  upon  the  fact  that  by  moderate  incineration  the  free  hydro- 
chloric acid  can  be  driven  off,  while  the  chlorin  in  combination  with 
the  inorganic  bases  is  not  affected. 

For  this  method  the  following  solutions  are  required: 

1.  A  decinormal  solution  of  hydrochloric  acid,  which  can  be 
prepared  by  standardizing  against  the  decinormal  caustic  soda  solu- 
tion as  described  in  a  former  chapter. 

2.  A  decinormal  solution  of  nitrate  of  silver,  containing  25  per 
cent,  of  pure  nitric  acid.  This  solution  is  approximately  made  up 
by  dissolving  17  gm.  of  pure  crystallized  nitrate  of  silver  in  900  c.c. 
of  a  25  per  cent,  solution  of  nitric  acid,  and  adding  50  c.c.  of  the 
liquor  ferri  sulphur  oxydati  of  the  German  Pharmacopeia  (the  liquor 
ferri  oxysulphatis  ["National  Formulary"]  will  serve  the  same  pur- 
pose). The  solution  is  then  standardized  against  the  solution  of 
hydrochloric  acid  and  diluted  to  the  proper  volume.  Each  c.c.  of 
the  solution  is  equivalent  to  0.00365  gm.  of  pure  hydrochloric  acid. 

3.  A  decinormal  solution  of  ammonium  sulphocyanate.  Eight 
gm.  of  the  pure  salt  are  dissolved  in  900  c.c.  of  distilled  water  and 
titrated  against  the  decinormal  solution  of  silver  nitrate.  After 
ascertaining  the  strength  of  this  solution  it  is  diluted  so  that  it  is 
exactly  equivalent  to  the  decinormal  solution  of  nitrate  of  silver. 

Method. — I.  To  determine  the  total  amount  of  chlorin  present  in 
the  gastric  juice,  10  c.c.  of  the  stomach  contents,  after  thorough 
mixing,  are  measured  into  a  small  cylinder  graduated  to  100  c.c, 
and  treated  with  20  c.c.  of  the  solution  of  nitrate  of  silver.  The 
mixture  is  thoroughly  shaken  and  allowed  to  stand  for  ten  minutes. 
The  mixture  is  then  diluted  to  100  c.c,  once  more  agitated,  and 
filtered  through  a  dry  filter  into  a  dry  flask.  Fifty  c.c.  of  the  filtrate 
are  then  titrated  with  the  decinormal  solution  of  ammonium  sul- 
phocyanate until  a  permanent  red  color  appears.  Multiply  the 
number  of  c.c.  of  ammonium  sulphocyanate  by  2,  as  only  half  the 
filtrate  was  taken,  and  subtract  from  the  number  of  c.c  of  nitrate 
of  silver  added  (20) ;  the  result  will  be  the  number  of  c.c  of  the 
nitrate  of  silver  solution  precipitated  by  the  total  chlorin  of  the 
gastric  juice  and  correspond  to  the  same  number  of  c.c  of  deci- 
normal solution  of  hydrochloric  acid,  the  whole  amount  of  chlorin 
being  expressed  in  terms  of  hydrochloric  acid. 


LEO'S    METHOD.  169 

2.  To  determine  the  amount  of  chlorin  in  combination  with  in- 
organic bases. 

Ten  c.c.  of  the  filtered  gastric  juice,  or  of  the  well-mixed  stomach 
contents,  are  evaporated  to  dryness  in  a  platinum  or  porcelain  cru- 
cible, over  a  water-bath  or  on  a  plate  of  asbestos,  to  avoid  loss  from 
sputtering.  The  incineration  is  carried  only  to  the  point  when  the 
residue  ceases  to  burn  with  a  luminous  flame.  After  cooling,  the 
residue  is  treated  with  distilled  water  up  to  about  100  c.c,  or  until 
the  filtrate  comes  away  free  from  chlorids,  which  may  be  shown  by 
treating  with  a  drop  of  silver  nitrate.  If  the  filtrate  remains  per- 
fectly clear  after  the  addition  of  a  drop  of  nitrate  of  silver,  the  residue 
is  free  from  chlorids.  To  the  clear  filtrate  is  now  added  ten  c.c. 
of  the  decinormal  solution  of  nitrate  of  silver,  and  the  excess  titrated 
by  means  of  the  decinormal  solution  of  ammonium  sulphocyanate 
as  before.  The  amount  of  ammonium  sulphocyanate  solution  sub- 
tracted from  the  amount  of  the  silver  solution  (ten  c.c.)  gives  the 
amount  of  silver  precipitated  by  the  chlorids  remaining  after  in- 
cineration in  combination  with  the  inorganic  bases.  By  subtracting 
the  result  of  the  second  process  from  that  of  the  first,  the  amount 
of  free  and  combined  hydrochloric  acid  is  determined. 

Modifications. — i.  By  titrating  with  decinormal  caustic  soda  solu- 
tion, using  dimethyl-amido-azo-benzol  as  an  indicator,  we  obtain 
the  amount  of  free  hydrochloric  acid ;  this  subtracted  from  the  sum 
of  the  free  and  combined  hydrochloric  acid  together,  as  arrived  at 
by  the  method  No.  2  on  previous  page,  will  give  the  amount  of  com- 
bined hydrochloric  acid. 

2.  By  determining  the  total  acidity  with  phenolphthalein  and  sub- 
tracting from  it  the  amount  of  free  and  combined  hydrochloric  acid, 
we  can  estimate  the  acidity  due  to  organic  acids  and  acid  salts. 

3.  The  amount  of  organic  acid  present  may  be  estimated  in  terms 
of  hydrochloric  acid  by  the  method  of  Hehner-Seeman  (to  be  de- 
scribed later).  This  result  deducted  from  the  result  of  the  preceding 
modification  gives  the  amount  of  acidity  due  to  acid  salts. 

Leo's  Method. — Leo  bases  his  method  upon  the  fact  that  when 
calcium  carbonate  is  added  in  a  fine  powder  to  the  gastric  juice  the 
free  and  combined  hydrochloric  acid  combine  with  the  calcium  car- 
bonate to  form  calcium  chlorid,  a  neutral  salt,  while  the  acid  salts 
are  not  affected.  During  the  reaction,  however,  the  calcium  chlorid 
reacts  with  the  phosphates  to  form  acid  calcium  phosphate  (mono- 
calcium  phosphate,  CaHP04).     As  this  requires  double  the  amount 


lyo  QUANTITATIVE   ESTIMATION   OP   LACTIC  ACID. 

of  caustic  soda  solution  to  neutralize  that  would  be  required  for  the 
acid  sodium  phosphate,  it  is  necessary  to  add  each  time  an  excess 
of  calcium  chlorid  solution  before  titration. 

Method. — Ten  c.c.  of  the  gastric  juice  are  shaken  up  with  50  c.c. 
of  ether  to  remove  organic  acids.  The  residue  after  drawing  off 
the  ethereal  layer  is  treated  with  five  c.c.  of  a  concentrated  solu- 
tion of  calcium  chlorid  and  titrated  with  the  decinormal  solution 
of  caustic  soda,  using  phenolphthalein  as  an  indicator.  This  deter- 
mines the  acidity  due  to  free  and  combined  hydrochloric  acid  and 
to  acid  salts.  A  second  portion  of  fifteen  c.c.  is  treated  with  a  small 
amount  of  pure,  dry  calcium  carbonate,  the  mixture  stirred  and 
immediately  filtered  through  a  dry  filter.  The  carbon  dioxid  is 
expelled  from  the  filtrate  by  passing  a  current  of  air  through  it. 
Ten  c.c.  of  the  filtrate  are  then  treated  with  five  c.c.  of  the  saturated 
solution  of  calcium  chlorid  and  titrated  as  above.  The  acidity 
found  is  due  to  the  acid  phosphates.  By  subtracting  the  result 
found  in  the  second  titration  from  that  of  the  first,  the  amount  of 
free  and  combined  hydrochloric  acid  is  determined. 

Boas'  Method. — This  method  is  an  easily  applied  test  for  free 
hydrochloric  acid,  which  gives  fairly  accurate  results  in  the  absence 
of  organic  acids  or  when  they  are  present  only  in  traces.  Ten  c.c. 
of  the  filtered  gastric  juice  are  titrated  with  decinormal  caustic  soda 
solution  until  a  small  amount  (a  drop)  removed  by  a  platinum  loop 
fails  to  change  the  tint  of  Congo  paper.  Instead  of  using  the  paper  as 
an  indicator  outside,  a  small  bit  of  the  Congo  paper  may  be  dropped 
into  the  solution  and  the  titration  conducted  slowly,  with  constant 
shaking,  until  the  paper  regains  its  original  red  color.  This  test, 
however,  can  not  be  employed  in  the  presence  of  any  considerable 
amount  of  free  organic  acids. 

Lactic  Acid — Quantitative  Estimation. — A  simple  clinical  test 
for  lactic  acid  has  been  devised  by  Strauss  ("Berliner  klin.  Woch.," 
1895,  No.  37).  A  separating  funnel  is  graduated  to  five  c.c.  below 
and  twenty-five  c.c.  above.  The  funnel  is  filled  to  the  five  c.c. 
mark  with  gastric  juice  and  ether  added  to  the  twenty-five  c.c.  mark. 
The  funnel  is  corked  and  well  shaken,  and  after  standing  for  a  short 
time  to  allow  the  fluids  to  separate,  the  liquids  are  run  out  to  the 
five  c.c.  mark.  Distilled  water  is  added  to  the  twenty-five  c.c.  mark 
and  the  mixture  treated  with  two  drops  of  a  solution  of  the  officinal 
tincture  of  the  chlorid  of  iron,  diluted  i  :  10.  On  shaking  the  mix- 
ture a  greenish-yellow  color  is  produced  if  lactic  acid  is  present  in 


QUANTITATIVE    ESTIMATION    OE    LACTIC    ACID. 


171 


25  c.c. 


5  c.c. 


the  proportion  of  i  per  1000  or  more.     If  present  in  the  proportion 
of  from  0.5  to  I  per  1000,  only  a  pale-green  color  is  produced. 

Boas'  Method.— This  method  of  esti- 
mating the  amount  of  lactic  acid  depends 
upon  its  oxidation  into  aldehyd  and  the 
estimation  of  the  latter  by  means  of  a 
standard  solution  of  iodin. 

Solutions  required:  i.  A  decinormal 
solution  of  iodin  is  prepared  by  dissolving 
twenty-five  gm.  of  potassium  iodid  in  about 
200  c.c.  of  water,  and  dissolving  in  this  12.6 
gm.  of  resublimed  iodin.  The  solution  is 
diluted  with  distilled  water  to  1000  c.c,  and 
requires  no  correction. 

2.  A  decinormal  solution  of  sodium  arse- 
nite:  Dissolve  16.5  gm.  of  sodium  arsenite 
in  about  900  c.c.  of  distilled  water.  It  is 
then  titrated  against  the  decinormal  solution 
of  iodin  and  diluted  so  that  the  two  solu- 
tions are  equivalent. 

3.  Hydrochloric  acid   (sp.  gr.    1018). 

4.  Normal  solution  of  potassium  hydrate 
(56  gm.  in  1000  c.c). 

Method :  Ten  or  twenty  c.c.  of  the  filtered 
gastric  juice  are  tested  for  the  presence  of 
free  acid;    if  present,    a   small   amount   of 

barium  carbonate  is  added  (if  free  acid  be  absent,  this  addition  is 
unnecessary)  and  evaporated  to  a  syrup.  A  few  drops  of  phosphoric 
acid  are  added  and  the  solution  boiled  sHghtly  to  expel  carbon  dioxid. 

Allow  the  syrup  to  cool;  extract  with  100  c.c.  of  ether  free  from 
alcohol;  after  the  two  fluids  have  separated  draw  off  the  ethereal 
solution;  evaporate;  take  up  the  residue  in  forty-five  c.c.  of  water, 
and  filter.  The  filtrate  is  treated  in  an  Erlenmeyer  flask  with  five  c.c. 
of  sulphuric  acid  and  a  small  amount  of  manganese  dioxid.  The 
flask  is  closed  by  a  two-holed  rubber  stopper,  one  aperture  being 
closed  by  a  glass  tube  and  rubber  tubing  clamped  off,  the  other 
opening  receiving  a  bent  glass  tube  leading  to  the  distilling  appa- 
ratus. The  distillate  is  received  in  a  large  flask  well  stoppered. 
The  mixture  is  distilled  at  a  gentle  heat  until  about  four-fifths  of 
the  fluid  has  passed  over.     The  distillate  is  then  treated  with  twenty 


Fig.  22.— Strauss'  Mixing 
Funnel  for  Lactic  Acid 
Determinations. 


172  ANALYSIS    OF    THE    STOMACH    CONTENTS. 

c.c.  of  the  decinormal  solution  of  iodin  and  the  same  amount  (twenty 
c.c.)  of  the  normal  potassium  hydrate  solution,  thoroughly  shaken 
and  allowed  to  stand  for  a  few  minutes  in  the  flask.  Twenty  c.c. 
of  hydrochloric  acid  and  an  excess  of  sodium  bicarbonate  in  powder 
are  then  added,  and  the  excess  of  iodin  determined  by  titration 
with  the  solution  of  sodium  arsenite.  The  sodium  arsenite  is  added 
until  the  solution  is  decolorized;  fresh  starch  solution  and  the  iodin 
solution  are  then  added  until  the  blue  color  becomes  permanent. 
Each  c.c.  of  the  iodin  solution  in  excess  of  the  sodium  arsenite  solu- 
tion is  equivalent  to  0.003388  gm.  of  lactic  acid. 

Quantitative  Estimation  of  Fatty  Acids. — Leo  ("  Centralblatt 
f.  d.  med.  Wissenschaften,"  1889)  has  recommended  the  following 
method:  The  total  acidity  of  the  gastric  juice  is  first  accurately 
determined.  Ten  c.c.  are  boiled  until  the  vapor  given  off  has  no 
longer  an  acid  reaction.  The  residue  is  then  titrated  with  ^  normal 
NaOH,  using  phenolphthalein  as  an  indicator.  The  loss  in  the  total 
acidity  gives  the  amount  of  the  fatty  acids.  This  method  does  not 
give  accurate  results,  as  some  HCl  is  given  off  in  the  boiling  process. 
By  determining  the  amount  of  HCl  before  and  after  the  boiling, 
the  amount  lost  is  determined  and  correction  can  be  made,  greatly 
increasing  the  accuracy  of  the  method  (Adler). 

Total  Organic  Acids. — The  total  organic  acids  are  best  esti- 
mated by  the  method  of  Hehner-Seeman,  called,  by  Leube,  Braun's 
method. 

Ten  c.c.  of  the  gastric  juice  are  accurately  neutralized  with  a  deci- 
normal solution  of  caustic  soda,  using  phenolphthalein  as  an  indi- 
cator. This  solution  is  then  evaporated  to  dryness,  carefully  avoid- 
ing sputtering,  and  incinerated  as  long  as  the  residue  burns  with  a 
luminous  flame.  After  cooling  the  residue  is  extracted  with  boihng 
distilled  water,  filtered,  and  the  amount  of  sodium  carbonate  formed 
determined  by  titration  with  a  decinormal  solution  of  hydrochloric 
acid.  As  the  presence  of  free  carbon  dioxid  interferes  somewhat 
with  the  delicacy  of  the  reaction  when  phenolphthalein  is  used  as 
an  indicator,  the  following  modification  has  given  better  results: 
After  the  incinerated  mass  has  been  extracted  with  boiling  water 
and  filtered,  a  known  excess  of  the  decinormal  solution  of  hydro- 
chloric acid  is  added,  the  solution  boiled  to  expel  any  carbon 
dioxid  in  solution,  and  the  excess  of  acid  determined  by  back  titra- 
tion with  a  decinormal  solution  of  caustic  soda. 

This  method  is  based  upon  the  fact  that  when  salts  of  the  organic 


SALIVA.  173 

acids  with  the  alkaHes  are  incinerated  at  a  low  heat  the  carbonates 
of  the  alkahes  are  formed  with  the  Hberation  of  water  and  carbon 
dioxid.  This  method  is  simple.  Martins  and  Liittke  speak  favor- 
ably of  it,  and  the  author  has  confirmed  its  accuracy  by  control 
analyses  with  other  methods. 


CHAPTER  XVIII. 

DIGESTIVE  FERMENTS.— PRODUCTS  OF  DIGESTION.— 
TESTS  FOR  SAME. 

Saliva.— The  saliva  as  found  in  the  mouth  is  the  mixed  secre- 
tions of  all  the  salivary  glands.  It  may  be  readily  obtained  for 
testing  by  requesting  the  individual  under  examination  to  chew  a 
piece  of  soft  rubber  or  other  insoluble  substance,  to  stimulate  the 
secretion,  and  as  it  forms  it  is  placed  in  a  clean  receptacle.  It  is 
a  clear,  slightly  opalescent  fluid,  of  a  mucoid  consistency,  having  a 
specific  gravity  of  from  1002  to  1006.  Under  normal  conditions  it 
has  a  slight  alkaline  reaction,  its  alkalinity  averaging  in  man  0.08 
per  cent.,  expressed  as  sodium  carbonate  (Chittenden). 

Its  active  constituent,  ptyalin,  acts  most  readily  upon  boiled 
starch,  raw  starch  being  protected  from  its  action  by  the  coating  of 
celluldse  surrounding  each  granule.  Its  action  is  entirely  amylo- 
lytic,  as  it  has  no  action  upon  other  food-products. 

Its  action  upon  starch  may  be  demonstrated  in  the  following 
simple  manner:  A  few  c.c.  of  boiled  starch-paste  are  treated  in  a 
test-tube  with  a  small  amount  of  saliva.  A  few  drops  removed  and 
treated  on  a  testing-plate  with  a  drop  of  iodin  solution  give  the 
characteristic  blue  color  of  starch.  After  a  moment  or  two  a  few 
drops  removed  will  show  a  violet  color,  and  by  treating  a  portion 
at  intervals  the  color  changes  gradually  to  a  deep  reddish  brown, 
and  finally  disappears.  Different  products  of  the  action  of  the  fer- 
ment are  found  at  different  stages  of  digestion.  The  violet  color 
first  found  is  a  color  which  results  from  a  mixture  of  erythrodextrin 
and  starch  when  treated  with  iodin.  Later  the  color  becomes 
reddish  brown,  due  to  the  change  of  the  starch  entirely  into  dex- 
trins  and  sugar.     When  digestion  has  gone  on  until  the  solution 


174  TESTS   FOR  PTYAUN. 

gives  no  color  whatever  witli  iodin,  the  solution  still  contains  some 
form  of  dextrin  (achroodextrin),  as  may  be  shown  by  the  addition 
of  alcohol,  which  throws  down  a  profuse  white  precipitate.  It  may 
be  shown,  also,  that  the  solution  contains  sugar  by  treating  a  small 
amount  of  the  mixture  with  Fehling's  solution.  This  sugar,  accord- 
ing to  the  investigations  of  Nasse,  von  Mehring,  and  Musculus,  is 
not  dextrose,  as  formerly  taught,  but  maltose. 

The  action  of  ptyalin  is  most  energetic  at  the  temperature  of  the 
body.  It  acts  best  in  a  neutral  medium,  though  a  small  trace  of 
alkali  has  little  or  no  effect  upon  it.  Its  activity  is  stimulated  by 
the  addition  of  enough  acid  to  combine  with  its  proteid  constituents. 
A  minute  trace  of  acid  still  allows  the  action  to  continue,  but  for 
practical  purposes  we  may  say  that  the  addition  of  free  acids,  in 
such  quantities  as  are  found  in  the  gastric  juice,  not  only  stops  its 
action,  but  possibly  destroys  the  ferment,  so  that  after  neutraliza- 
tion it  is  no  longer  able  to  digest  starch. 

In  the  stomach  the  action  of  the  ptyalin  probably  continues  until 
the  presence  of  free  acid  destroys  the  ferment.  As  no  free  acid  can 
normally  be  demonstrated  in  the  stomach  until  the  lapse  of  fifteen 
or  twenty  minutes,  the  greater  portion  of  the  starch  is  transformed 
into  sugar  and  achroodextrin.  Under  normal  conditions,  then,  we 
should  find,  in  the  gastric  juice  removed  for  examination,  sugar, 
achroodextrin,  and  a  faint  trace  of  erythrodextrin.  The  presence 
of  a  marked  reaction  of  erythrodextrin  may  be  taken  as  valuable 
presumptive  evidence  of  hyperacidity,  its  absence  indicating  either 
normal  acidity  or  subacidity. 

Only  in  rare  instances  has  absence  of  ptyalin  from  the  saliva 
been  seen. 

There  are  some  unexplained  cases  in  which,  with  a  normal  or 
diminished  acidity,  the  digestion  of  starches  is  very  poor,  as  is  shown 
by  the  marked  reaction  of  erythrodextrin  and  the  small  percentage 
of  sugar  found  by  quantitative  test.  The  amylolytic  power  of  the 
salivary  excretion  ought  always  to  be  examined  in  such  cases. 

Pepsin.— The  proteolytic  ferment  of  the  gastric  juice  is  active 
only  in  an  acid  medium,  and  is  destroyed  by  very  dilute  solutions 
of  the  alkaline  carbonates.  Pepsin  is  probably  not  secreted  as  such, 
its  precursor  being  pepsinogen  or  propepsin,  which  is  transformed 
by  weak  acids  into  the  active  ferment,  pepsin.  While  hydrochloric 
acid  acts  best  in  thus  transforming  pepsinogen  into  pepsin,  other 
acids  to  a  lesser  degree  can  perform  the  office.     Pepsin,  like  the 


TESTS   FOR   PEPSIN.  I  75 

other  ferments,  has  the  property  of  changing  an  almost  unlimited 
amount  of  proteids,  providing  the  products  of  its  action  are  removed 
when  formed,  and  the  temperature  kept  at  a  favorable  point,  as  it 
appears  to  act  by  its  presence,  not  being  itself  destroyed  or  changed 
by  the  reaction. 

While  it  has  never  been  isolated  in  a  pure  state,  we  know  that  a 
product  can  be  obtained  by  complex  chemical  methods  which,  while 
intensely  proteolytic,  exhibits  none  of  the  reactions  of  proteids;  so 
that  the  ferment,  whatever  its  nature,  is  probably  not  a  proteid. 

The  amount  of  acid  necessary  for  the  most  vigorous  action  of 
pepsin  varies  with  the  form  of  proteids  employed.  For  example, 
pepsin  acts  best  on  fibrin  when  the  acidity  is  about  i  :  looo,  while 
coagulated  egg-albumen  is  digested  most  rapidly  when  the  acidity 
amounts  to  two  or  three  per  thousand  of  hydrochloric  acid. 

Test. — Three  test-tubes  or  small  wine-glasses  are  taken,  and  a 
small,  thin  slice  of  boiled  egg-albumen  placed  in  each.  To  the  first 
is  added  three  c.c.  of  the  gastric  juice;  to  the  second,  three  c.c.  of 
the  gastric  juice  to  which  hydrochloric  acid  has  been  added  in  suffi- 
cient quantity  to  bring  the  acidity  to  two  or  three  per  thousand ;  the 
third  is  acidulated  as  in  number  two  and  a  few  grains  of  pepsin 
added.  The  three  tubes  or  glasses  are  now  placed  in  the  in- 
cubator, at  a  temperature  of  40°  C,  and  allowed  to  remain  for 
three  hours. 

If  at  the  end  of  this  time  all  three  tubes  show  digestion  by  the  solu- 
tion of  the  egg-albumen,  the  specimen  contained  pepsin ;  if  numbers 
two  arid  three  only  show  digestion,  the  contents  contained  pepsinogen 
but  no  pepsin;  while  if  only  the  third  tube  or  glass  shows  traces  of 
digestion,  the  specimen  contained  neither  pepsin  nor  pepsinogen. 

Pepsinogen. — This  substance  is  supposed  to  be  secreted  by  the 
cells  of  the  gastric  mucosa,  and  to  be  changed  into  pepsin  by  the 
action  of  the  hydrochloric  acid  of  the  gastric  juice.  This  action  has 
been  differently  explained  by  various  experimenters,  the  most 
plausible  theory  being  that  a  combination  of  the  two  takes  place 
with  the  formation  of  pepsin — hydrochloric  acid. 

In  the  absence  of  hydrochloric  acid,  this  body,  pepsinogen,  may 
be  present  in  normal  amount,  and  require  only  the  addition  of  a 
sufficient  quantity  of  hydrochloric  acid  to  bring  the  gastric  juice  to 
a  normal  acidity  to  render  the  stomach  contents  active. 

In  the  absence  of  free  hydrochloric  acid  we  may  test  for  the  pres- 
ence of  this  substance  by  acidulating  with  hydrochloric  acid,  as  in 


176  DEJTECTION   OF   RENNIN. 

number  two  of  the  pepsin  test,  adding  a  small  bit  of  boiled  egg- 
albumen  and  placing  in  the  thermostat  at  a  temperature  of  40°  C. 
for  three  hours,  at  the  end  of  this  time  noting  the  presence  or  absence 
of  signs  of  digestion. 

The  test  proposed  by  Hammerschlag  for  the  peptonizing  power 
of  the  gastric  juice  has  been  highly  recommended  in  the  recent 
works  on  gastric  diseases.  It  is  carried  out  in  the  following  manner : 
A  solution  of  about  one  per  cent,  of  albumen  containing  0.4  per 
cent,  free  hydrochloric  acid  is  prepared,  and  ten  c.c.  added  to  each 
of  two  tubes.  To  one,  the  control-tube,  five  c.c.  of  distilled  water, 
to  the  other  five  c.c.  of  the  gastric  juice,  are  added,  and  both  tubes 
set  in  the  incubator  for  one  hour  at  body-temperature.  At  the  end 
of  this  time  the  amount  of  albumen  in  each  tube  is  estimated  by 
the  Esbach  albuminometer,  the  difference  between  the  two  tubes 
showing  the  amount  of  digested  albumen. 

Two  objections  may  be  brought  against  this  method:  (i)  The 
Esbach  albuminometer  is  by  no  means  an  accurate  method  of  esti- 
mating the  amount  of  albumen;  (2)  peptones  are,  in  part  if  not 
completely,  precipitated  by  picric  acid  in  the  cold. 

Boas,  following  out  the  observations  of  Briicke  ("Vorlesungen 
iiber  Physiologic,"  p.  311,  1884:  Quantitative  Determination  of 
Pepsin,  etc.),  employs  a  comparative  test  which  in  doubtful  cases  may 
yield  valuable  information.  Properly  labeled  tubes  are  prepared, 
and  in  them  are  placed  measured  quantities  of  gastric  juice  diluted 
with  a  solution  of  hydrochloric  acid  of  the  normal  strength  of  the 
gastric  juice  (two  or  three  per  1000),  so  that  the  tubes  contain  the 
gastric  juice  in  dilutions  of  i  :  10  and  i  :  20.  To  each  tube  a  small 
flake  of  egg-white  or  fibrin  is  added  and  put  in  a  thermostat  at  the 
temperature  of  the  body.  From  the  amount  of  dilution  at  which 
digestion  ceoses,  an  idea  may  be  gained  of  the  amount  of  pepsin  or 
pepsinogen  which  any  gastric  juice  contains.  For  comparison, 
similar  tubes  may  be  prepared  of  normal  gastric  juice,  and  the 
digestive  power  of  the  two  compared. 

Chymosin  or  Rennin  and  Rennin  Zymogen. — In  addition  to 
pepsin,  the  gastric  juice  also  contains  a  ferment,  or  its  zymogen, 
whose  special  property  appears  to  be  the  precipitation  of  casein 
from  milk.  As  in  the  transformation  of  pepsinogen  into  pepsin 
hydrochloric  acid  is  required,  so  rennin  zymogen  in  the  gastric  juice 
is  not  transformed  into  rennin  except  in  the  presence  of  hydrochloric 
acid.     Certain  neutral  salts  of  lime,  such  as  calcium  chlorid,  how- 


TEST   FOR   RENNIN   ZYMOGEN.  177 

ever,  have  the  power  of  transforming  rennin  zymogen  into  rennin, 
even  in  neutral  or  slightly  alkaline  solutions. 

The  following  tests  for  the  presence  of  rennin  and  its  zymogen 
have  been  devised  by  Boas: 

^g^^,-^._Five  c.c.  of  the  gastric  juice  are  exactly  neutralized 
with  a  decinormal  solution  of  caustic  soda,  five  c.c.  of  neutral  milk 
added,  and  the  mixture,  after  being  weU  shaken,  is  placed  in  an 
incubator  at  the  body-temperature. 

If  rennin  be  present,  the  casein  will  form  a  firm  coagulum  in  from 
ten  to  fifteen  minutes. 

A  relative  quantitative  estimation  of  the  rennin  ferment  may  be 
performed  by  the  following  method : 

The  gastric  juice  is  accurately  neutralized  and  portions  of  this 
diluted  with  distilled  water,  in  known  proportions,  i  :  lo,  i  :  20,  etc. 
To  five  c.c.  of  each  of  these  dilutions  five  c.c.  of  neutral  milk  are 
added,  and  the  tubes  placed  in  the  thermostat  at  the  body-temper- 
ature 'for  fifteen  minutes.  At  the  end  of  this  time  the  tubes  are 
removed  and  the  dilution  at  which  no  coagulation  takes  place  is 
noted.  In  stating  the  dilution  note  must  be  taken  of  the  fluid  added 
in  neutralizing. 

Rennin  Zymogen.— Viv^  c.c.  of  the  gastric  juice  are  rendered 
faintly  alkaline  by  the  addition  of  a  decinormal  solution  of  caustic 
soda;  one  c.c.  of  a  one  per  cent,  solution  of  calcium  chlorid  and 
five  c.c.  of  neutral  milk  are  added.  The  tube  is  placed  in  the  ther- 
mostat, and  after  fifteen  minutes  should  show  a  firm  cake  of  casein 
if  rennin  zymogen  be  present. 

QuanUtaU've.—'t\i^  gastric  juice  is  rendered  faintly  alkaline  by 
adding  a  decinormal  solution  of  caustic  soda  and  dilutions  prepared, 
I  :  10,   I  :  20,    etc.,  estimating  in  the  dilution  the  amount  of  fluid 
added  in  alkalinizing.     Five  c.c.  of  each  of  these  dilutions  are  placed 
in  test-tubes  with  five  c.c.  of  neutral  milk  and  one  c.c.  of  a  one  per 
cent,  solution  of  calcium  chlorid.     These  are  placed  in  a  thermostat 
at  the  body-temperature,  and  at  the  end  of  fifteen  minutes  the  dilu- 
tion at  which  the  enzyme  fails  to  act  is  noted.     From  the  observa- 
tions of  Boas  and  others  it  appears  that  the  secretion  of  the  ferments 
and  the  pro-enzymes  is  less  affected  by  the  minor  disturbances  which 
may  cause  a  temporary  arrest  of  the  acid  secretion  of  the  stomach. 
Decrease  in  the  activity  of  the  ferments,  on  the  other  hand,  is  usually 
the  result  of  some  organic  change  in  the  gastric  mucosa. 

By  experiment  upon  normal  individuals  it  has  been  found  that 


178  PRODUCTS    OF    PEPSIN    DIGESTION. 

rennin  is  active  in  dilutions  of  from  i  :  30  to  i  :  40,  and  rennin  zymo- 
gen in  dilutions  varying  from  i  :  100  to  i  :  150.  It  has  been  found 
that,  even  in  the  absence  of  free  hydrochloric  acid,  the  ferments 
may  be  active  up  to  the  limit  observed  in  normal  individuals,  and 
that  in  such  cases  the  condition  of  anacidity  was  a  temporary  matter, 
due  to  some  mental  or  circulator}^  disturbance,  the  acid  reappearing 
when  the  cause  of  the  disturbance  w^as  removed. 

On  the  other  hand,  in  cases  of  anacidity  in  which  the  rennin 
zymogen  was  active  only  in  the  stronger  dilutions,  i  15,  i  :  10,  etc., 
the  anacidity  is  due  to  some  organic  change  in  the  gastric  mucosa 
from  which  recovery  is  usually  rare. 

It  wiU  be  seen  from  these  considerations  of  what  importance  a 
quantitative  investigation  of  the  gastric  ferments  is  from  the  prog- 
nostic standpoint. 

Action  of  Pepsin  on  Proteids.— The  action  of  pepsin  upon 
proteids  only  takes  place  to  a  slight  extent  in  a  neutral  solution. 
Faust  ("Zur  Kentniss  des  Pferdeblutserumalbumins,"  u.  s.  w.  ; 
"Archiv  f.  experiment.  Pathol,  u.  Pharmakol.,"  Bd.  vli)  has  shown 
that  crystallized  serum-albumin,  when  treated  with  a  neutralized 
extract  of  the  gastric  mucous  membrane,  gives  off  to  the  fluid  a 
small  amount  of  a  highly  nitrogenous  neutral  body,  possibly  a 
cyanamid.  In  acid  solution  the  action  is  a  very  complex  one  and 
not  as  yet  fully  understood.  The  first  observable  result  of  the 
action  of  a  hydrochloric  acid  solution  of  pepsin  upon  a  coagulated 
albumen,  such  as  egg-white,  is  apparently  a  partially  mechanical 
change.  The  egg-white  swells  up,  its  edges  become  rounder,  and 
it  becomes  clearer  and  more  glassy  in  appearance.  The  egg-white 
then  begins  to  dissolve,  as  is  shown  by  the  presence  in  the  solution 
of  a  substance  precipitated  by  neutralization,  which  ma}^  be  called 
syntonin,  or  acid-albumin.  This  action  takes  place  also  in  acid 
solutions  to  which  pepsin  has  not  been  added.  The  next  step  is 
one  in  which  the  pepsin  plays  an  important  part.  The  syntonin  or 
acid-albumin  is  changed  first  into  the  primary  albumoses,  proto- 
and  hetero-albumose.  These  undergo  further  change  and  become 
deutero-albumoses,  and,  finally,  peptones.  These  substances  may 
be  distinguished  from  each  other  by  the  following  reactions: 

(o)  Native  albumins  may  be  removed  from  the  solution,  if  present, 
by  rendering  the  stomach  contents  faintly  acid,  if  not  already  so, 
and  boiling.  The  precipitate  will  consist  of  the  native  proteids,  viz., 
albumin  and  globulin. 


SEPARATION   OP   ALBUMOSES.  1 79 

(6)  The  solution  is  carefully  neutralized  by  the  addition  of  a  weak 
caustic  soda  solution.  The  precipitate  will  consist  of  syntonin  or 
acid-albumin.  The  neutralization  must  be  exact,  as  the  precipitate 
is  dissolved  by  an  excess  of  acid  or  alkali  to  form  acid-albumin  or 
alkali-albumin,  respectively. 

(c)  The  filtrate  from  which  the  albumin  and  acid-albumin  has 
been  removed  is  now  saturated  with  magnesium  sulphate  and  fil- 
tered. The  precipitate,  which  consists  of  the  primary  albumoses, 
proto-  and  hetero-albumoses,  is  dissolved  in  water,  placed  in  a 
dialyzer,  and  the  salts  removed  by  dialysis.  As  hetero-albumose  is 
insoluble  in  pure. water,  it  is  precipitated  by  the  removal  of  the 
salts,  as  in  a  dialyzer.  The  proto-albumose  remains  in  solution,  as 
it  is  soluble  in  water,  and  may  be  tested  for  by  acidulating  with 
nitric  acid  in  the  cold,  the  precipitate  redissolving  on  heating. 

(d)  Deutero-albumose,  or  secondary  albumose,  is  detected  in  the 
following  manner:  A  sufficient  quantity  of  the  gastric  juice  is  freed 
from  albumen  and  acid-albumin,  according  to  (a)  and  (b).  The 
filtrate  is  saturated  with  powdered  ammonium  sulphate  and  the 
precipitate  which  forms,  consisting  both  of  primary  and  secondary 
albumoses,  is  filtered  off,  and  washed  thoroughly  with  a  saturated 
solution  of  ammonium  sulphate. 

The  precipitate  is  redissolved  in  the  least  amount  of  water  pos- 
sible, faintly  acidulated  with  acetic  acid  and  saturated  with  common 
salt,  which  precipitates  the  primary  albumoses,  leaving  the  deutero- 
albumose,  or  secondary  albumose,  in  solution.  After  filtration  the 
secondary  albumose  may  be  detected  by  saturating  again  with 
ammonium  sulphate  any  precipitate  which  may  form  consisting  of 
deutero-albumose.  It  may  be  detected  also  by  adding  a  consider- 
able amount  of  common  salt  to  its  solution  and  acidulating  with 
nitric  acid.  A  precipitate  will  form  in  the  presence  of  deutero-albu- 
mose, redissolved  on  heating. 

(e)  Peptone  may  be  detected  by  precipitating  all  the  other  pro- 
teids  by  saturating  with  ammonium  sulphate  and  filtering.  The 
filtrate  contains  the  peptone,  which  may  be  tested  for  by  the  biuret 
reaction.  The  filtrate  is  treated  with  an  excess  of  caustic  alkali 
and  a  few  drops  of  a  very  dilute  solution  of  copper  sulphate.  If 
peptones  are  present  in  the  solution  a  pink  or  rose-red  color  appears. 

Under  some  circumstances  the  precipitation  of  the  albumoses  by  am- 
monium sulphate  is  incomplete,  and  in  these  cases  the  method  given 
by  Miiller  ("Zeit.  f.  phys.  Chemie,"  Bd.  XX vi,  S.  48)  gives  good  results. 


l8o  GASTROSCOPY. 

The  stomach  contents  are  treated  with  an  equal  volume  of  a 
thirty  per  cent,  solution  of  ferric  chlorid,  nearly  neutralized  by  the 
addition  of  a  solution  of  caustic  soda  and  filtered.  The  filtrate  is 
treated  with  a  small  amount  of  zinc  carbonate,  well  shaken  and 
again  filtered.  The  filtrate  is  clear  and  colorless,  and  may  now  be 
tested  by  the  biuret  reaction  as  given  above. 


CHAPTER  XIX. 
GASTROSCOPY, 


Although  the  method  and  instruments  for  directly  inspecting  the 
interior  of  the  stomach  are  by  no  means  perfect,  the  author  has 
considered  it  practical  to  insert  this  account  of  the  procedure  because 
of  its  undoubted  future  development  as  a  diagnostic  aid. 

The  first  one  to  use  a  gastroscope  was  Mikulicz  ("Ueber  Gas- 
troskopie  u.  Oesophagoskopie,"  "Wien.  med.  Presse,"  1881,  No.  43; 
also  "Wien.  med.  Wochenschr.,"  18S3,  Nos.  23  and  24).  The  in- 
strument used  was  made  by  Leiter,  of  Wien,  and  was  curved  at  an 
obtuse  angle.  The  following  account  of  the  technic  and  value  of 
the  method  is  quoted  from  Rosenheim  {loc.  cit.) : 

"Gastroscopy  is  founded  on  the  fact  discovered  by  this  author, 
that  in  the  majority  of  cases  (eighty  per  cent.)  it  is  possible  to  in- 
troduce, without  special  difficulty,  a  straight,  rigid  tube,  twelve  mm. 
in  diameter,  the  patient  having  first  been  placed  in  the  dorsal  posi- 
tion. It  is  possible  to  introduce  such  a  tube  far  into  the  stomach, 
often  as  far  as  the  navel,  and  eventually  below  [the  same.  The 
establishment  of  this  fact  first  furnished  him  with  a  foundation  on 
which  gastroscopy  could  be  developed,  after  he  had  come  to  the 
conclusion  that  an  optical  apparatus,  to  be  suitable  for  the  stomach, 
must  be  straight  as  in  the  cystoscope"  (Rosenheim,  "Gastroskopie," 
"Berlin,  klin.  Wochenschr.,"   1896,  No.   13). 

Apart  from  complications  that  are  due  to  tumors,  exudations, 
enlargement  of  the  liver,  etc.  (that  is,  to  the  pathological-anatomical 
conditions),  apart  also  from  congenital  anomalies  (abnormally  con- 
torted course  of  the  esophagus  or  abnormal  contraction),  two  facts 
are  to  be  considered  in  the  light  of  an  impediment  to  a  successful 
probing  by  means  of  introducing  a  rigid  tube  into  the  stomach:  In 


DESCRIPTION    OF    GASTROSCOPE. 


l8l 


t>i 


the  first  place,  the  bend  to  the  left,  or  spiral  twist,  which  the  esoph- 
agus shows  so  frequently  in  its  subphrenic 

part;   and,  secondly,   the   occurrence   of  ^ 

spasm  at  the  lower  physiological  contrac-  w       ■  tu 

tion  of  the  organ.  With  continued  prac- 
tice it  becomes  apparent  that  the  ana- 
tomical obstruction,  caused  by  the  change 
in  the  direction  of  the  esophagus,  may 
usually  be  overcome  if  the  instrument  is 
introduced  from  the  right  angle  of  the 
mouth,  preferably  while  the  head  is  turned 
slightly  to  the  right,  laterally. 

The  obstruction  before  the  cardia, 
caused  by  spasm  of  the  muscles  of  the 
esophagus,  can  not  be  eliminated  me- 
chanically ;  here  the  manner  of  introduc- 
ing  the  tube   makes   no  difference,   and 

soothing    the    patient,    persistence,    and 

adaptation  can  alone  lead  to  the  desired 

result.     Local  anesthesia  is  useless.    How 

much  the  occurrence  of  the  spasm  is  due 

to  the  psychic  condition  of  the  patient 

was    shown   by    numerous   observations 

with  invalids,   particularly  neurasthenic 

presons,  who  were  timid  and  restive  when 

the  probe  was  first  introduced,  and  with 

whom  it  was  impossible  to  penetrate  to 

the  stomach ;  while  later,  after  they  had 

become  familiar  with  the  proceeding,  this 

was  easily  accomplished.     It  is  necessary 

to  keep  in  mind,  also,  that  the  spasm  ap- 
pears more  frequently  with  persons  who 

are  suffering  with  an  ulcer  or  carcinoma 

near  the  cardia. 

Description  of  the  Instrument. — 
(See  Fig.  23.)  The  gastroscope  is  a 
straight  metal  instrument,  68  cm.  in 
length,  12  mm.  in  diameter,  consisting 
of  three  concentric  syster^s  of  tubes, 
and  terminating  in  a  larger  head-piece  p  c.  23.-gastroscopk. 


1 82  GASTROSCOPY. 

for  the  different  conduits.  The  inner  tube  (i)  forms  an  optical  appa- 
ratus, the  ocular  of  which  is  situated  at  O,  and  a  rectangular  prism, 
P,  is  located  in  front  of  its  objective  lenses.  The  visual  angle  of  the 
telescope  (otherwise  constructed  according  to  the  principle  which  has 
been  approved  in  the  cystoscope,  viz.,  as  a  terrestrial  telescope) 
amounts  to  60°,  so  that  it  is  possible  to  inspect  an  area  five  cm.  in 
diameter  at  a  distance  of  five  cm.  from  the  object.  The  center  of  the 
portion  in  view  lies  vertically  over  the  small  side  (cathetus)  of  the 
rectangular  prism  which  receives  the  image.  In  order  to  inspect  a 
surface  the  center  of  which  does  not  lie  at  right  angles  over  the  cath- 
etus, the  rectangular  prism  may  be  replaced  by  an  acute  angular 
prism;  by  this  means  those  surfaces  also  can  be  examined  that  are 
situated  above,  which  can  be  only  partially  viewed  by  means  of  a 
rectangular  prism.  The  absolute  necessity  of  inspecting  parts  of  the 
stomach  which  appear  at  varying  heights — for  instance,  the  region  of 
the  pylorus — explains  this  arrangement. 

The  optical  apparatus  is  inclosed  by  a  tube  (3)  that  is  closed  at 
the  lower  end  by  a  head-piece.  A,  carrying  a  tip  of  rubber,  G.  Just 
above  the  tip  there  is  an  aperture,  F,  which  is  closed  by  a  glass 
window,  behind  which  there  is  situated  an  incandescent  lamp,  as 
shown  in  5.  At  the  upper  and  lower  ends  of  the  lamp  the  metal 
contacts  that  conduct  the  current  are  fastened.  Above  the  window 
there  is  a  second  aperture,  B,  in  which  the  prism  is  adjusted,  and 
inside  of  which  it  may  even  be  moved  up  or  down.  In  the  tube  (3) 
there  are  four  canals  separated  from  one  another.  Two  of  these 
canals,  which  end  at  C  and  D,  serve  to  conduct  water  through  the 
instrument  and  around  the  lamp,  to  prevent  excessive  heating  of 
the  tubes  caused  by  the  incandescent  lamp.  The  third  canal  is  used 
to  receive  the  wires  that  conduct  the  current  to  the  lamp ;  while  the 
fourth  canal,  which  begins  at  /  and  opens  at  the  lower  end  of  the 
instrument  behind  the  window,  F,  is  used  to  introduce  air,  which 
must  be  pumped  into  the  stomach,  by  means  of  a  blast,  to  distend 
its  walls.  Toward  the  top  the  thin  tube  terminates  in  a  larger  head- 
piece that  establishes  the  connection  of  the  canals  with  the  different 
conduits  for  water,  air,  and  electricity. 

Figure  23  (i)  shows  the  sliding  tube,  a  tube  with  a  centimeter 
scale,  that  can  be  shoved  over  the  instrument  (3)  and  easily  re- 
volved on  the  same.  It  has  an  aperture  at  E  corresponding  to  the 
aperture  B,  and,  by  being  turned  180  degrees,  it  serves  to  cover 
this  aperture,  as  well  as  the  prism  lying  behind  the  same,  so  as  to 


DESCRIPTION    OP    GASTROSCOPE.  1 83 

prevent  the  optical  apparatus  from  being  soiled  by  mucus  while  the 
instrument  is  being  introduced.  If  the  external  tube  is  so  adjusted 
that  the  aperture  B  is  closed,  and  if,  to  further  protect  the  optical 
apparatus,  the  latter  is  turned  i8o  degrees  so  that  the  exposed 
surface  of  the  prism  faces  the  side  of  the  tube,  then  the  prism  enjoys 
a  double  protection,  and  in  consequence  the  instrument  can  not  be 
soiled  while  being  introduced.  Small  metal  knobs  are  attached  to 
the  top  of  all  three  tubes,  to  enable  us  to  control  from  the  outside 
their  position  in  the  stomach;  when  these  stand  in  a  straight  line 
the  observer  knows  that  the  prism  is  not  covered  by  the  revolving 
tube,  but  faces  the  cavity  of  the  stomach  through  the  aperture. 
The  electric  current  -|-  and  —  is  introduced  at  the  points  of  contact 
by  means  of  a  movable  cable  that  is  equipped  with  an  interrupter. 
The  intensity  of  the  electric  current  is  sixteen  volts.  In  conducting 
water  through  the  apparatus  a  stand  carrying  an  irrigator  is  used. 
The  two  rubber  tubes  conduct  the  water  through  the  instrument. 
By  means  of  a  cock  the  flow  of  the  water  can  be  interrupted.  An- 
other tube  carries  the  water  that  has  passed  through  the  instrument 
into  the  water-bucket.  To  cool  the  instrument  it  is  advisable  to  use, 
not  cold  water,  but  water  of  about  40°  C,  in  order  that  the  lenses  of 
the  optical  apparatus  and  the  surfaces  of  the  prism  may  not  be 
covered  with  a  film  of  moisture  caused  by  sudden  condensation. 
The  stand  carries  the  accumulator  (storage  battery)  used  to  furnish 
the  electricity;  this  is  supplied  with  a  rheostat  for  regulating  the 
current,  and  also  with  an  interrupter. 

It  is  absolutely  necessary  in  every  case  to  convince  ourselves, 
before  carrying  out  the  gastroscopic  investigation,  that  the  way 
from  the  teeth,  as  far  as  the  great  curvature,  is  really  unobstructed, 
and  no  special  difficulties  are  offered  to  the  passage  of  a  straight 
rigid  tube  while  the  patient  occupies  the  dorsal  position.  This  test 
should  never  be  neglected.  At  the  same  time  the  procedure  should 
be  carried  out  with  the  greatest  caution. 

Rosenheim  employs  for  this  purpose  a  hollow  steel  probe  seventy 
cm.  long,  and  having  the  diameter  of  the  gastroscope  (12  mm.),  or 
a  smaller  one,  ending  likewise  below  in  a  rubber  appendage,  in  the 
side  of , which  there  is  a  small  aperture  provided  with  a  blast ;  the 
parts  can  be  screwed  off  to  facilitate  cleansing;  a  centimeter  scale 
is  engraved  on  the  sides.  This  probe  is  introduced  in-  the  dorsal 
position,  preferably  from  the  right  corner  of  the  mouth ;  after  measure- 
13 


184  PROCEDURE    OF    GASTROSCOPY. 

ments  along  the  back  have  been  made  to  determine  the  distance  of 
the  cardia  from  the  teeth,  and  after  having  apphed  a  four  per  cent, 
solution  of  cocaine  to  the  pharynx,  the  patient  is  directed  to  breathe 
quietly  and  deeply,  and  to  lift  his  right  hand  on  feeling  a  pain  in  the 
region  of  the  stomach  or  above  the  same.  If  the  patient  shows  pain, 
the  procedure  must  cease  at  once.  If  resistance  is  felt,  a  moment 
of  rest  intervenes,  or  eventually  the  instrument  is  retracted  a  little, 
only  to  try  again  whether  the  resistance  yields  under  gentle  pressure, 
the  reaction  on  the  part  of  the  patient  meanwhile  determining  the 
degree  of  energy  that  is  to  be  employed  in  this  manipulation.  The 
absolute  law  in  probing  is  to  avoid  all  strong  pressure,  otherwise 
lesions  of  the  membrane,  even  perforation  of  the  esophagus  or  stom- 
ach, may  be  the  consequence.  After  the  diaphragm  has  been  passed, 
air  is  pumped  into  the  stomach  and  we  determine  how  far  the  instru- 
ment is  able  to  penetrate  into  the  inflated  organ. 

The  correct  guiding  of  the  instrument  from  the  right  comer  of 
the  mouth  plays  an  important  part  in  the  success  of  introducing  the 
instrument  in  the  majority  of  cases. 

If  we  wish  to  get  our  bearings  and  inform  ourselves  by  means  of 
the  telescope  about  the  vast  cavity  of  the  stomach,  it  is  preferable 
to  start  from  the  normal  position  just  described:  The  point  of  the 
instrument  far  down  at  the  great  curvature,  the  window  turned  to 
the  front.  In  this  position  the  front  wall  of  the  stomach  approaches 
the  eye  closeh^,  within  from  two  to  three  cm.,  so  that  we  see  it  magni- 
fied. A  hasty  glance  suffices  to  recognize  the  condition  of  the 
mucous  membrane  here,  and  we  then  immediately  change  the  posi- 
tion of  the  instrument  by  revolving  it  slowly  to  the  right  so  that 
the  prism  faces  the  pylorus.  This  part  of  the  stomach  and  the 
adjoining  portion  of  the  small  curvatine  vary  in  their  distance  from 
the  prism  in  various  cases.  The  distance  is  from  six  to  twelve  cm., 
and  the  image  which  we  receive  of  this  section  is,  therefore,  usually 
somewhat  reduced  in  size  (to  about  one-half).  We  now  are  ex- 
amining a  part  of  the  organ  that,  from  a  practical  point  of  view,  is 
perhaps  the  most  important,  since  ulcers  and  cancers  are  so  fre- 
quently located  there.  We  exert  ourselves  now,  starting  from  the 
opening  of  the  pylorus,  to  investigate  systematically  the  whole 
hoUow  cone,  situated  to  the  right.  This  part  does  not  escape  us, 
as  a  rule,  if  we  move  the  tube  gradually  from  the  great  curvature 
upward  while  revolving  the  apparatus  generally  in  both  directions. 
After  we  have  found  the  orifice  of  the  stomach,  as  a  fixed  point,  it 


THE    ESOPHAGOSCOPE. 


185 


is  not  difficult  to  espy  from  the  same  the  neighboring  section  of 
the  small  curvature,  at  least,  and  something  of  the  rear  wall.  The 
higher  the  portio  pylorica  lies  behind  the  liver,  the  more  it  (as  is 
normal)  bends  away  to  the  rear  on  the  right,  the  more  difficult  it  is 
to  inspect,  while  a  low  position  greatly  facilitates  our  investigation. 
In  the  former  case  (for  which  we  may  be  somewhat  prepared  by 


Fig.  24. 
1.  Esophagoscope.     2.  Obturator.     3.  Esophageal  forceps.    4.  Esophageal  applicator. 

(Rosenhemi.*) 

the  preceding  inflation  of  the  stomach)  the  optical  apparatus  pro- 
vided with  an  acute-angled  prism  is  recommended.  It  is  possible 
to  recognize  how  different  the  distance  is  between  the  prism  and 
the  pylorus  during  the  normal  position  of  this  segment  of  the  organ 
and  during  dislocation  of  the  same.     In  the  former  case  the  distance 


*  Our  thanks  are  due  to  Professor  Theod.  Rosenheim  (Berlin)  for  presentation  of  these 
illustrations. 


1 86  GASTROSCOPY. 

is  more  considerable;  we  must  withdraw  the  instrument  farther,  to 
bring  at  least  a  part  of  the  portio  pylorica  within  the  angle  of  the 
prism ;  and  if  the  point  of  the  instrument  diverges  a  little  farther  to 
the  left  from  the  vertebral  column,  this  approach  to  the  cardia  avails 
nothing;  under  all  circumstances  we  receive  only  an  image  of  the 
part  beneath  the  orifice  of  the  stomach.  During  these  manipulations 
we  are  in  danger  of  being  surprised  by  an  obscuring  of  the  field  of 
vision,  since  we  are  compelled  to  approach  closely  the  descending 
part  of  the  small  curvature  adjoining  the  cardia.  These  disturbances 
are  avoided  if  we  take  a  view  of  the  pyloric  portion  from  a  deeper 
point,  a  thing  which  can  be  conveniently  effected  by  the  employment 
of  an  acute-angled  prism  in  the  apparatus ;  the  center  of  the  circle, 
which  we  then  survey,  no  longer  stands  perpendicularly  over  the 
prism.  We  no  longer  receive  the  image  from  a  region  at  the  same 
level  with  the  prism,  but  from  one  a  little  higher. 

If  the  pyloric  portion  is  dislocated  to  the  lower  margin  of  the 
liver,  or  deeper,  the  rectangular  prism  opposite  the  same  can  easily 
be  adjusted  without  needing  a  correction. 

After  inspecting  the  pyloric  portion  we  approach  the  great  curva- 
ture with  the  point  of  the  gastroscope,  and  turn  the  instrument  to 
the  left  by  i8o  degrees;  while  slowly  withdrawing  the  instrument, 
we  next  inspect  the  part  of  the  fundus  and  cardiac  portion  that 
belong  to  the  left  half  of  the  body.  The  investigation  is  now  com- 
pleted ;  the  illumination  is  discontinued,  the  revolving  tube  is  pushed 
in  front  of  the  window,  the  blast  is  removed  in  order  that  the  gases 
may  quickly  escape;  only  after  this  is  the  instrument  withdrawn. 
Rosenheim  has  devised  a  gastroscope  more  recently  in  which  the  stream 
of  water  for  the  cooling  of  the  electric  lamp  is  dispensed  with ;  the  lamp 
is  only  flashed  now  and  then,  and  not  kept  incandescent  continuously. 
The  latter  instrument  is  thinner  and  only  ten  mm.  in  diameter. 

Conclusion. — (i)  Not  all  parts  of  the  interior  of  the  stomach 
can  be  inspected.  Portions  of  the  greater  curvature — of  the  pos- 
terior wall,  the  immediate  neighborhood  of  the  cardia — are  not 
visible.     It  can  not  be  practised  on  all  individuals. 

(2)  All  suspected  cases  of  ulcer  must  be  excluded  if  recent  pain 
and  hemorrhages  have  occurred.  Ulcers  at  pylorus  are  less  liable 
to  be  injured  than  those  near  the  cardia. 

(3)  Rosenheim  suggests  that  gastroscopy  may  be  employed  for 
the  early  diagnosis  of  carcinoma  and  its  differentiation  from  ulcer. 
It  is  an  inconvenient  procedure  and  very  difficult  of  execution,  and 
not  free  from  danger. 


PART  SECOND. 

THERAPY   AND   MATERIA   MEDICA   OF  STOMACH 

DISEASES. 


CHAPTER  I. 

THE    PRINCIPLES   OF   DlETEtlC    TREATMENT    OF 
GASTRIC    DISEASES. 

In  the  chapter  on  the  Physiology  of  Digestion  we  have  briefly 
considered  the  various  food-substances,  their  nutritious  and  innu- 
tritions constituents,  the  amounts  of  each,  requisite  to  maintain  a 
healthy  organism,  and  their  caloric  values,  etc.  It  is  one  of  the 
far-reaching  deserts  of  the  great  Father  of  Medicine  to  have  first 
methodically  developed  dietetics  for  the  sick  as  a  special  discipline 
and  an  integral  part  of  therapy. 

In  his  classical  dissertation  on  the  conduct  of  febrile  diseases 
(Hippocrates,  "De  victus  ratione  in  morbis  acutis"),  in  his  aphor- 
isms, and  in  many  other  treatises,  he  emphasizes  the  great  importance 
of  careful  regulation  of  nutrition  for  patients.  His  principles,  based 
upon  analytical  experience,  are  stated  with  unsurpassable  precision. 
His  dietetics  are  free  from  speculation,  and  regard  the  nature  and 
stage  of  the  disease,  the  constitution,  age,  and  habits  of  the  patient ; 
above  all,  they  show  what  is  in  our  days  termed  an  individualizing 
principle.  It  would  seem  probable  that  a  therapeutic  aid  that  had 
been  logically  considered  at  the  very  dawn  of  medical  knowledge, 
and  by  such  an  able  mind,  would  at  the  present  time  be  one  of  the 
most  highly  developed  in  medicine,  particularly  when  one  reflects 
upon  the  declaration  of  Bonders  ("Die  Nahrungsstoffe  des  Mens- 
chen,"  Crefeld,  1853):  "Whoever  works  at  the  development  of  our 
knowledge  of  food-substances  is  working  on  a  broad  basis  for  the 
development  of  mankind."  Fortunately  for  us,  many  bright  in- 
tellects have  already  applied  themselves  to  this  work,  and  our  knowl- 

187 


1 88  DIETETIC   TREATMENT   OF    GASTRIC    DISEASES. 

edge  has  been  enriched  by  treasures  of  valuable  information.  But 
the  well-advised  special  student  can  not  fail  to  recognize  that  we 
have  only  entered  a  vast  territory,  and  that  the  greater  part  of  it 
remains  to  be  explored.  Even  the  small  portion  which  by  hard 
toiling  is  clearly  our  own  is,  we  regret  to  say,  far  from  being  the 
common  property  of  the  profession — at  least,  it  does  not  seem  to  be 
taken  advantage  of;  the  profession  at  large  failing  to  realize  that  a 
logical  and  individualizing  diet  is  a  more  potent  therapeutic  factor 
than  medicine. 

The  results  so  far  obtained  show  great  domains  of  research  and 
inquiry  yet  to  be  explored  for  truth  bearing  on  dietetics.  And 
many  of  our  present  results  demand  reconsideration  for  correct  in- 
terpretation. Various  eminently  fitted  observers  disagree  on  vital 
dietetic  questions,  because  the  special  point  of  view  from  which 
each  one's  research  ("Fragestellung")  was  undertaken  was  not  iden- 
tical, sometimes  not  defined  with  precision.  Sometimes  the  intri- 
cacy of  the  question  to  be  solved  did  not  permit  of  direct  methods 
of  investigation,  and  indirect  methods  had  to  be  employed. 

The  scales  of  digestibility  of  various  foods,  as  devised  b}^  Leube 
and  Penzoldt,  for  instance,  were  arrived  at  by  determination  of  the 
time  which  the  stomach  required  to  discharge  these  foods  into  the 
duodenum.  Evidently  the  term  "digestibility"  means  the  rate  of 
solution  of  the  various  food-substances  by  the  constituents  of  the 
gastric  juice,  or  of  the  intestinal  juices,  as  the  case  may  be.  Diges- 
tibility, therefore,  has  reference  mostly  to  secretion,  but  the  rate  of 
the  gastric  expulsion  of  chyme  is  a  problem  of  motility. 

To  be  of  easy  digestibility  food-substances  must — 

1.  Offer  only  a  slight  resistance  to  the  digestive  juices — i.  e.,  the}'' 
must  be  of  easy  solubility. 

2.  They  must  not  impede  or  accelerate  peristalsis. 

3.  They  must  not  excessively  irritate  the  digestive  organs,  either 
mechanically  or  chemically. 

4.  They  must  not  increase  the  processes  of  fermentation  or  putre- 
faction. 

5.  The  greater  portions  of  the  substance  must  be  absorbable  either 
in  the  stomach  or  intestines. 

To  say  that  veal  in  amounts  of  100  gm.  leaves  the  stomach  in  one 
to  two  hours  does  not  imply  that  it  is  digestible,  for  the  same  may 
be  said  of  sawdust  (from  actual  experiment  of  a  colleague,  made 
upon  himself).     By  our  method  of  duodenal  intubation  we  sue- 


CRITERION   OF   DIGESTIBILITY.  I09 

ceeded  in  regaining  from  the  duodenum  56.4  per  cent,  of  a  weighed 
amount  of  ingested  veal  two  hours  and  fifteen  minutes  after  it  had 
been  eaten.  The  veal  was  weighed  and  was  easily  recognizable; 
besides,  nothing  else  had  been  eaten  at  the  time.  The  celerity  with 
which  a  food  disappears  from  the  stomach,  therefore,  is  not  so  much 
an  indication  of  its  digestibility  as  it  is  of  the  gastric  motor  power. 

A  more  correct  way  to  determine  the  digestibility  of  various 
foods— one  which  we  have  systematically  experimented  with  on  a 
number  of  volunteers  from  our  classes  who  had  a  normal  digestion- 
is  to  find  out  how  much  by  weight  of  a  known  amount  of  ingested 
food  is  converted  into  peptone  or  dextrose  and  maltose,  as  the  case 
may  be,  in  a  given  time— for  instance,  one  hour  or  thirty  minutes. 

In  a  large  number  of  these  experiments  we  aspirated  some  of  the 
weighed  test-meals  from  the  duodenum  (method  of  the  author. 
Boas'  "Archives  for  Digestive  Diseases,"  vol.  11).  For  approxi- 
mately accurate  results  it  is  sufficient  to  weigh  the  insoluble  residue 
of  the  particular  food  that  is  drawn  out  of  the  stomach.  It  is  neces- 
sary to  have  those  experiments  which  are  to  serve  as  crucial  tests 
of  digestibihty  made  with  comparatively  pure  proteids,  such  as  meat 
and  egg,  and  pure  carbohydrates,  such  as  rice.  The  amount  of  water 
used  in  the  cooking  and  the  amount  ingested  must  be  known,  and 
can  be  found  out  by  evaporating  control  samples  to  dryness. 

It  may  thus  be  learned  how  much  proteid  is  rendered  soluble  by 
the  pepsin  hydrochloric  acid,  how  much  casein  is  digested,  or  how 
much  of  starch  is  converted  into  dextrose  and  maltose  in  the  fifteen 
to  forty-five  minutes,  or  any  desired  period  during  which  the  par- 
ticular ferments  are  permitted  to  act.  The  results  can  naturally 
not  be  absolutely  correct,  but  only  relatively  so ;  at  least,  they  are 
more  nearly  correct  than  the  conditions  of  the  experiment  will  allow 
the  results  of  Leube  and  Penzoldt  to  be. 

The  absolute  amount  of  food  need  not  be  regained;  all  that  is 
required  for  a  comparative  study  is  to  learn  in  a  given  sample— say, 
thirty  c.c— the  proportion  of  soluble  and  insoluble  chyme.  Dex- 
trose present  can  be  determined  by  titration,  as  we  have  shown  else- 
where; and  from  the  reactions  of  the  various  transition  products 
from  proteid  to  peptone  the  amount  of  the  latter  can  also  be  approx- 
imately known,  particularly  if  the  amount  of  solid  residue  of  proteid 
that  can  be  regained  is  learned  first. 

It  is  an  interesting  fact  that  the  results  of  these  tests  of  digesti- 
bility performed  directly  on  the  normal  stomach  can  be  confirmed 


190  DIieTKTiC   TREATMENT  OF   GASTRIC   DISEASES. 

by  control  analysis,  made  with  animals  (making  allowance  for  the 
increased  secretion  of  HCl  in  dogs),  and  by  analysis  made  with  arti- 
ficial digestive  mixtures  in  the  incubator.  In  the  chapter  on  Diges- 
tion by  Pepsin  it  has  been  explained  why  the  exact  gastric  digestion 
can  not  be  imitated  in  a  test-tube,  mainly  because  the  formation 
of  peptone  in  the  stomach  remains  at  a  certain  percentage  by  the 
absorption  of  peptones  over  that  amount.  As  soon  as  the  amount 
of  peptone  exceeds  a  certain  percentage  it  retards,  and  may  even 
suspend,  proteolysis.  The  retardation  of  proteolysis  which  occurs 
in  hyperacidity  may  be  explained  in  this  way — i.  e.,  more  peptone  is 
formed  in  a  given  time  than  normally,  and  as  it  can  not  be  absorbed 
as  rapidly  as  it  is  formed,  it  inhibits  further  proteolysis  by  its  pres- 
ence; besides,  the  stomach  attempts  to  maintain  a  fairly  constant 
degree  of  concentration  of  contents  by  removal  of  chyme  into  the 
duodenum. 

Notwithstanding  all  these  differences,  test-tube  or  artificial  diges- 
tion experiments  are  very  valuable  for  comparative  studies  in  diges- 
tibility, particularly  when  deductions  are  made  in  combination  with 
test-meals  on  the  normal  and  diseased  human  stomach.  In  the 
stomach,  we  must  bear  in  mind,  there  is  a  carbohydrate  and  a  pro- 
teid  digestion;  we  can,  however,  rarely  give  food  exclusively  from 
the  standpoint  of  gastric  digestion,  for  IvCube  and  Penzoldt's  tables 
show  that  the  greater  portion  of  the  digestive  work  is  executed  in 
the  intestine. 

Our  results,  so  far  as  we  can  judge  at  present,  agree  with  the  main 
ones  of  these  observers.  Leube  studied  the  duration  of  retention 
of  various  foods  in  the  stomachs  of  diseased  patients,  and  Penzoldt 
in  the  stomachs  of  healthy  individuals  (that  is,  before  they  were 
expelled  in  the  duodenum).  We  have  confirmed  their  principles 
by  experiments,  ascertaining  the  amounts  of  proteid  and  carbo- 
hydrates converted  into  a  soluble  form  in  a  given  time  in  normal 
and  pathological  stomachs.  These  experiments  were  supported  by 
tests  made  with  artificial  digestive  mixtures  and  on  dogs. 

The  explanation  of  the  agreement  of  these  various  methods  of 
testing  digestibility  is  probably  the  fact  that  food-substances  which 
are  most  rapidly  and  thoroughly  converted  into  a  soluble  form  are 
also  most  easily  expelled  into  the  intestines.  Easily  soluble  proteids, 
though  solid,  are  readily  converted  into  a  liquid  or  at  least  semi- 
solid form,  in  which  they  are  readily  propelled  onward.  Proteid 
soluble   with   difficulty   is   retained   longer,    because   the   preantral 


ADAPTATION    OF    DIET.  19  ^ 

sphincter  has,  to  a  degree,  a  selective  action,  and  will  not  readily 
permit  the  passage  of  solid  food.  The  matters  of  solution  and  rate 
of  propulsion  of  foods  are,  then,  the  factors  which  are  intimately 
correlated  and  largely  go  to  make  up  the  quality  of  digestibility. 
The  definition  of  a  digestible  food,  then,  is  one  that  makes  relatively 
small  demands  upon  the  secretory  and  motor  functions  of  the  stom- 
ach, which  is  readily  absorbed  and  produces  no  subjective  complaints 
or  feeling  of  discomfort. 

From  a  pathological  point  of  view,  however,  the  conception  of 
digestibility  is  a  variable  one.  Foods  that  may  be  easily  digestible 
for  a  gastric-ulcer  patient  may  be  very  indigestible  for  a  case  of 
atrophic  gastritis  or  of  cancer.  Leube  and  Penzoldt's  method  of 
estimating  gastric  digestibility  by  the  rate  at  which  various  foods 
are  expelled  into  the  duodenum,  gives  a  relatively  correct  indica- 
tion for  the  sound  normal  organ,  because  secretory  and  motor  func- 
tions are  equally  taxed  as  they  go  hand  in  hand. 

The  results  can  not  be  unconditionally  applied  to  abnormal 
states  where  one  or  the  other  function,  or  both,  are  disturbed,  some- 
times in  opposite  directions,  secretion  increased,  motility  diminished, 
or  vice  versa.  There  are  conditions  in  which  gastric  digestion  is  com- 
pletely destroyed  and  must  be  replaced  by  the  intestinal  function. 
There  are  states  of  absolute  and  permanent  loss  of  gastric  secretion 
(achyha),  in  which  the  propulsion  of  food  from  the  stomach  is  not 
delayed.  Now,  one  can  not  speak  of  gastric  digestibility  in  these 
cases,  because  there  is  very  little,  if  any;  but  such  cases  may  have 
a  perfect  intestinal  digestion,  so  that  the  distinction  between  "gas- 
tric" and  "intestinal  digestibility"  is  important. 

The  diet  of  patients  must  be  varied  and  adapted  to  the  condition 
of  the  gastric  secretion,  motility,  and  absorption;  but  it  must  also 
—and  this  is  generally  overlooked— be  adapted  to  the  sensibility 
of  the  stomach.  The  neuroses  of  sensation,  considered  in  the  clin- 
ical portion  of  this  work,  offer  a  fertile  field  of  work  to  the  thoughtful 
dietarian.  An  abnormally  increased  feeling  of  hunger,  in  which 
this  intensely  heightened  sensation  can  hardly  be  appeased  by  food 
and  absence  of  the  feeling  of  ssitisLtion,— bulimia  and  akoria,— as 
well  as  absence  of  hunger,  in  which  the  appetite  is  very  readily  ap- 
peased, can  in  many  cases  be  successfully  treated  by  diet. 

By  treating  bulimia  dietetically,  we  do  not  mean  to  suggest  un- 
limited ingestion  of  food,  but  rather  a  painstaking  investigation 
of  the  cause,  which  may  be  an  unduly  large  stomach  or  convalescence 


192  =   DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

from  infectious  disease  (typhoid).  We  do  not  class  the  increased 
desire  for  food  observed  in  men  performing  exceptional  physical 
work,  in  women  during  pregnane}^  and  lactation,  as  well  as  in  rapidly 
growing  children,  as  bulimia.  This  augmentation  of  hunger  is  due 
to  a  greater  requirement  of  food,  because  the  organism  has  greater 
expenses  in  supplying  material  for  growth  or  energy.  Many  forms, 
perhaps  sixty  per  cent.,  of  bulimia  cases  are  due  either  to  hyper- 
esthesia, hyperacidity,  or  hypermotility.  If  these  are  causes,  the 
treatment  given  under  these  diseases  should  be  administered  (clin- 
ical part).  The  meals  should  be  allowed  every  two  or  three  hours 
and  consist  largely  of  such  proteids  as  have  a  great  combining  affinity 
for  HCl.  These  are  given  under  Fleischer's  list  of  the  HCl  binding 
power  of  foods.  But  if  an  irritative  state  of  the  glandular  layer 
can  be  ascertained,  the  diet  should  be  largely  amylaceous.  If  the 
motility  be  exaggerated  with  the  hyperacidity,  it  is  well  to  direct 
the  patient  to  drink  frequently  of  cold  alkaline  waters,  such  as  the 
Saratoga  Vichy,  or  the  alkaline  effervescent  water  recommended 
by  Jaworski  (see  clinical  part),  particularly  when  the  stomach  is 
empty. 

Anorexia,  in  its  severe  forms,  is  most  often  due  to  organic  changes 
in  the  gastric  walls.  In  the  nervous  forms  it  is  often  benefited  b}^ 
a  course  of  forced  feeding  with  the  stomach-tube.  Persistent  ano- 
rexia in  highly  neuropathic  individuals  had,  in  fact,  best  be  treated 
this  way  as  soon  as  the  patients  positively  refuse  food,  because  a 
complete  cure  can  frequently  be  accomplished  by  gavage  alone. 
The  feeding  through  the  tube  has  a  moral  and  educational  effect 
not  to  be  underestimated.  In  my  experience  as  ph3^sician-in-charge 
of  Bay  View  Asylum,  many  cases  were  observed  to  resume  taking 
their  meals  with  good  appetite  as  soon  as  they  became  convinced 
that  forced  feeding  would  be  insisted  upon.  But  aside  from  this 
moral  effect  there  is  also  a  physiological  one:  this  consists  in  the 
supplying  of  a  stimulant  to  the  stomach  in  the  form  of  food.  Nour- 
ishment is  the  proper  stimulant  to  secretion,  and  if  it  is  wanting  for 
a  long  time  the  functions  of  the  stomach  soon  become  arrested,  and 
with  them  the  appetite.  The  nutritive  stimulant  to  the  gastric 
mucosa  is  food;  it  causes  a  fiUing  of  the  blood-  and  lymph-vessels, 
thus  indirectly  bringing  about  a  better  nutrition  of  the  histological 
elements  of  the  mucosa  and  a  resumption  of  HCl  formation  with 
ferments,  which  in  anorexia  is,  as  a  rule,  suppressed.  In  fact,  as 
appetite  causes  eating  in  the  healthy,  so  eating  will  cause  appetite 


EFFECT   OF   ABSORPTION   ON   SELECTION   OF   DIET.  1 93 

in  these  cases  of  anorexia.  In  mild  cases  of  anorexia  a  sensation 
of  hunger  is  frequently  started  up  by  salty  and  "piquante"  articles, 
such  as  caviar,  sardelles,  herrings,  etc.,  and  at  the  same  time  small 

It 

doses  of  alcohol  with  bitter  tonics,  such  as  the  Angostura  bitters, 
are  advisable.  The  extractive  substances  in  fresh  meats  (bouillon) 
are  stimulants  to  appetite  (Pawlow).  Lavage  with  solutions  of 
chlorid  of  sodium  or  a  .04  per  thousand  HCl  is  most  effective.  The 
most  essential  condition  to  a  proper  dietetic  treatment  is,  of  course, 
that  the  patient  should  have  appetite.  A  great  point  is  gained  if 
he  can  be  made  to  take  food  with  pleasure.  For  the  management 
of  those  cases  with  anorexia  we  must  refer  to  the  article  on  this 
subject. 

The  author  agrees  with  Sir  William  H.  Broadbent  ("Brit.  Med. 
Jour.,"  vol.  II,  1893,  p.  1268)  when  he  says:  "In  all  cases  in  which 
the  cause  has  been  overfeeding  or  improper  food,  or  food  taken  at 
a  wrong  time,  an  extremely  strict  and  meager  diet  for  a  few  days 
will  be  the  best  treatment.  No  advantage  is  gained,  however,  from 
a  low  diet  in  neurotic  cases. 

"The  object  we  set  before  ourselves  must  be,  not  to  level  down 
the  diet  to  the  digestive  capabilities  of  the  stomach,  but  to  level  tip 
the  digestion  till  it  can  deal  efficiently  with  the  amount  of  food  for 
the  due  support  of  the  nervous  system.  No  hard  and  fast  rule 
can  be  laid  down.  Speaking  generally,  such  a  (neurotic)  patient 
will  digest  food  which  he  relishes  better,  even  if  it  have  the  reputa- 
tion of  being  indigestible,  than  the  most  digestible  and  scientifically 
prepared  food  which  he  eats  by  order,  and  dislikes.  A  very  common 
experience  is  that  he  is  tempted  by  a  good  dinner,  eats  largely  and 
indiscriminately,  and  then,  instead  of  a  bad  night  and  great  dis- 
comfort, which  he  thinks  he  has  deserved,  he  sleeps  well  and  feels  all 
the  better  for  his  indiscretion." 

A  very  important  point  will  be  to  disabuse  the  patient's  mind  of 
the  idea  that  pain  after  meals  necessarily  indicates  that  the  food 
has  been  unsuitable.  One  day,  and  under  one  set  of  circumstances, 
anything  will  agree;  on  another  day,  under  different  circumstances, 
nothing  is  digested.  Directions  must  be  given  not  to  eat  when 
exhausted  or  excited  or  anxious,  not  to  jump  from  meals  and  rush 
off  to  work  of  any  kind,  and  to  eat  very  slowly. 

The  state  of  the  gastric  absorption  has  to  be  considered  in  the 
selection  of  a  diet.  In  most  text-books  this  factor  of  dietetics  is 
entirely  neglected.     In  the  light  of  the  most  modern  knowledge  on 


194  DmTKTiC   TREATMENT   OF   GASTRIC   DISEASES. 

absorption,  that  furnished  by  the  work  of  von  Mehring,  according 
to  which  it  is  almost  limited  to  cane-,  grape-,  and  milk-sugar,  mal- 
tose, dextrin,  alcohol,  and  peptone,  while  water  is  not  at  all  absorbed 
(see  Absorption),  it  is  not  at  once  evident  why  the  state  of  absorption 
should  be  considered  in  selecting  a  diet.  Von  Mehring's  results, 
however,  seem  to  point  the  way  in  selecting  peptones,  maltose, 
dextrin,  alcohol,  etc.,  where  we  must  depend  on  rapid  diffusion  of 
nutritious  material,  and  also  in  avoiding  water,  or  foods  containing 
water,  where  the  gastric  walls  are  weak,  because  it  is  not  absorbed 
and  overdistends  by  its  weight.  Not  only  this,  but  simultaneously 
with  resorption  a  more  or  less  active  excretion  of  water  occurs  into 
the  stomach.  The  amount  of  this  excretion  of  water  increases  or 
diminishes  with  the  quantity  of  substances  resorbed  or  taken  up. 
Certain  gastric  diseases  connected  with  much  fermentation  are  sup- 
posed to  be  in  etiological  relation  with  tonic  muscular  spasms — forms 
of  tetany  of  gastric  origin.  Bouveret  and  Devic  ("Rech.  clin.  et 
experim.  sur  la  tetanic  d'origine  gastrique,"  "Revue  de  Med.,"  1892, 
XII,  p.  48)  assert  that  alcohol  is  instrumental  in  favoring  the  forma- 
tion of  an  intragastric  diffusible  toxin  in  dilations  and  hypersecretive 
states,  and  that  these  poisons  bring  about  the  spasms.  Fleiner  {loc. 
cit.)  and  Kussmaul  recommend  that  no  alcohol  in  any  form  be  given 
in  dilatations  with  pyloric  stenosis,  where  naturally  the  absorption  of 
the  alcohol  must  be  very  much  retarded.  The  latter  authors  do 
not  accept  the  toxic  origin  of  the  spasms,  but  suggest  that  the  alcohol 
causes  a  tremendous  excretion  of  water  into  the  stomach,  thus  rob- 
bing the  organism  of  a  requisite  amount, — a  tetany,  therefore,  due 
to  drying  of  muscles  and  nerves ;  both  views  are  merely  hypotheses. 
The  practical  deduction  is  that  where  the  absorption  has  been  found 
defective  by  tests,  alcohol  had  best  be  avoided. 

Boas  recommends  that  explicit  written  directions  be  given  to  each 
patient  after  the  diagnosis  has  been  made,  concerning — 

1.  Exact  time  of  meals. 

2.  An  exhaustive  account  of  articles  of  diet  and  luxury  that  are 
allowed.* 

3.  An  exact  statement  of  the  weights  and  measurements  of  the 
foods  and  beverages. 

4.  Brief  instructions  on  the  preparation  of  the  food,  temperature 
of  drinks,  seasoning,  etc. 

*  Dr.  E.  R.  Schreiner  has  devised  a  useful  diet-list  by  which  the  physician  is  enabled 
to  rapidly  fulfil  this  desideratum.      (Published  by  P.  Blakiston's  Son  &  Co.,  Phila.) 


PREPARATION    OF   FOOD.  195 

5.  Special  account  of  foods  that  are  forbidden. 
The  time  for  the  ingestion  of  food  is  an  essential  factor  in  dietetics, 
particularly  with  our  American  business  men,  with  whom  it  is  a 
common  practice  to  sacrifice  meal  hours  to  business.  The  hours  for 
meals  should  be  religiously  observed  by  gastric  sufferers,  and  the 
hours  for  stomach-rest  or  fasting  also.  Hyperacidity  and  forms  of 
nervous  dyspepsias  occasionally  require  small  meals  frequently  re- 
peated ;  the  same  is  true  of  some  types  of  atonic  and  stenotic  gastrec- 
tasias,  where  the  chyme  still  reaches  the  duodenum  but  with  difficulty. 
Other  stomach  diseases  require  long  pauses  of  rest  between  the 
meals,  and  it  is  not  always  possible  to  state  a  priori  how  much  diges- 
tive work  and  how  much  rest  any  particularly  diseased  stomach 
may  require.  It  is  only  after  a  prolonged  study  of  the  various 
gastric  functions  that  the  physician  can  give  correct  instruction  in 
chronic  cases  (see  chapter  on  the  Use  and  Abuse  of  Rest,  etc.). 

There  is  much  need  for  enlarging  the  dietetic  menu  of  dyspeptics ; 
nothing  should  be  forbidden,  except  there  are  actual  facts  founded 
on  experiment,  the  nature  of  the  disease,  or  the  idiosyncrasies  of 
the  case  proving  it  to  be  harmful.  Our  experience  is  that  when  the 
menu  is  too  limited  a  certain  disgust  for  the  diet  eventually  becomes 
manifest,  resulting  either  in  temporary  anorexia  or  a  disregard  of 
the  directions  and  indulgence  in  forbidden  foods. 

Directions  as  to  preparations  of  the  food  are  sometimes  neces- 
sary. Here  the  physician  must  be  able  to  indicate,  for  instance  in 
an-  or  subacidity  or  atrophic  gastritis,  that  the  meats  should  be  finely 
scraped  or  cut,  then  cooked  in  a  steam  broiler,  with  a  liberal  sea- 
soning of  pepper  and  salt.  In  hyperacidity,  gastroxynsis,  gastritis 
acida,  and  the  convalescence  from  gastric  ulcer,  all  seasoning  except 
a  little  salt  must  be  avoided;  wherever  there  is  excess  of  HCl  the 
meats  should  also  be  finely  divided  before  cooking.  The  amounts 
of  paprika,  red  and  black  pepper,  mustard,  horse-radish,  lemon, 
vinegar,  and  ginger,  that  can  be  allowed  in  cases  of  absolute  sup- 
pression of  secretion  (as  these  materials  have  some  effect  in  stimu- 
lating secretion),  must  be  stated. 

The  preparation  of  soups  and  gravies,  the  amounts  and  kinds  of 
fats  and  sugars  to  be  used  in  the  cooking,  are  points  of  importance. 
For  a  more  detailed  account  of  these  indispensable  methods  and 
directions  for  preparations  of  food,  reference  must  be  had  to  works 
on  Dietetics,— i;i(ie  Oilman  Thompson,  Munk  and  Uffelmann,  Wiel 
("Tisch  fur  Magenkranke"),  Boas  ("Diat  u.  Wegweiser  f.  Magen- 


196  DIETETIC    TREATMENT   OF    GASTRIC    DISEASES. 

kranke"),  Woltering  (" Diatetisches  Handbuch"),  Yeo  ("Food  and 
Diet"),  Penzoldt  (vol.  iv  of  the  "Handbuch  f.  spezielle  Therapie  "), 
Honigmann  ("Zeitschr.  f.  Krankenpflege,"  1894,  No.  8),  Wegele 
("  Diatetische  Behandl.  d.  Magen-  u.  Darmkrankh."),  Leyden 
(" Ernahrungstherapie  u.  Diatetik"),  Moritz  ("Die  Krankenernah- 
rung,"  Universal-Lexikon  der  Kochkunst,  2  vols.,  published  by  J.  J. 
Weber,  Leipzig).* 

The  Diet  as  Influenced  by  the  State  of  the  Secretion. — The 
anomalies  of  secretion  are:  (i)  Hyperacidity,  (2)  Sub-  and  Anacidity, 
which  form  one  group  of  gastric  neuroses.  In  another  group  we 
may  classify  hypersecretion  (of  normal  gastric  juice  in  which  the 
HCl  is  not  increased  or  diminished).  This  is  the  "Magensaftfiuss" 
of  Reichmann,  the  gastrosuccorrhea  chronica  or  periodica,  of  which 
Schreiber  holds  that  it  is  not  a  disease  sui  generis.  We  class  the 
so-called  "gastroxynsis"  of  Rossbach  with  the  hypersecretions,  be- 
cause it  impresses  us  to  be  a  gastric  neurosis  with  excessive  secretion 
and  hemicrania,  and  is  hardly  entitled  to  be  classed  as  a  distinct 
and  separate  disease. 

As  far  as  diet  is  concerned,  the  hypersecretions  do  not  exactly 
coincide  with  the  hyperacidity  in  the  treatment.  For  the  augmented 
gastric  juice  in  the  super-  or  hypersecretions  may  be  a  passive  act 
on  the  part  of  the  glands,— their  activity  may  be  kept  up  by  retained 
food.  But  in  hyperacidity  the  excessively  high  percentage  of  HCl 
is  an  active  process,  an  irritative  state  of  the  mucosa  in  which  it 
responds  with  excessive  formation  of  acid  to  all  food  stimuli.  In 
the  hypersecretions  the  diet  should  be  selected  with  regard  to  favor- 
ing rapid  gastric  evacuation.  In  hyperacidity  there  is  no  better 
treatment  than  rest.  These  are  states  in  which  there  is  an  accel- 
erated digestion  of  albuminous  and  proteid  foods,  and  a  retardation 
of  carbohydrate  digestion,  which  is  caused  by  an  inhibition  of  the 
inverting  action  of  the  diastase  of  the  saliva,  the  ptyalin  by  the  ex- 
cessive amount  of  HCl.  The  same  is  true  of  the  pancreas  diastase. 
Boas  has  shown  {loc.  cit.)  that  a  neutralization  of  the  chyme  will 
restore  the  diastatic  action,  but  we  have  assured  ourselves  that  if  the 
gastric  acidity  has  once  reached  0.3  per  cent,  the  action  of  the  ptyalin 
can  not  again  be  so  perfectly  restored  by  neutralization  with  sodium 
carbonate  as  it  was  before.     In  other  words,  excessive  hyperacidity 


*A    Complete    Encyclopeedia    on    the    Art    of   Cooking,  Preserving,   Table  Ethics, 
Menus,  etc. 


DIET    IN    HYPERACIDITY    AND    HYPERSECRETION.  197 

permanently  damages  the  ptyalin.  It  may  resume  some  inverting 
action  after  neutralization,  but  it  is  not  equal  to  that  evinced  during 
the  first  forty-five  minutes  of  normal  gastric  digestion.  An  intensely 
acid  gastric  juice  will  produce  a  deleterious  effect  on  the  bile  by  pre- 
cipitating from  it  a  substance  up  to  the  present  time  not  isolated, 
by  which  the  bile  aids  in  partial  digestion  of  the  fats.  In  a  similar 
way  the  secretion  of  the  pancreas  is  prevented  from  performing  its 
work,  because  it  can  do  so  only  in  an  alkaline  or  faintly  acid  medium. 
There  are  three  organic  diseases  which  dietetically  come  under  this 
group  of  excessive  acidity  or  secretion ;  these  are  ulcer,  gastritis  acida, 
and  ulcus  carcinomatosum.  Concerning  the  dietetic  treatment  of 
hyperacidities,  uniformity  of  opinion  does  not  exist.  As  a  general 
rule,  it  can  be  stated  that  in  the  simple  forms  a  bland,  unirritating 
diet,  which  at  the  same  time  binds  as  much  hydrochloric  acid  as 
possible,  should  be  prescribed.  We  favor  a  diet  that  does  not  irritate 
the  mucosa  any  more  than  is  absolutely  necessary.  There  are  two 
indications:  (i)  An  etiological  one,  directed  to  the  condition  of  the 
mucosa  and  demanding  rest  for  the  irritative  state  present;  (2)  a 
symptomatic  one,  directed  to  neutralization  of  the  excess  of  HCl 
by  diet  having  the  greatest  HCl-binding  affinity.  These  two  indi- 
cations are  to  some  extent  opposed  to  one  another.  The  etiological 
indication  necessitates  avoidance  of  albuminous  food,  for  in  our  ex- 
perience proteid  and  albuminous  foods  produce  an  increased  secre- 
tion of  HCl.  The  second  or  symptomatic  indication  calls  for  a  large 
ingestion  of  albumen  to  combine  with  the  HCl.  In  case  of  ulcer 
the  food  must  be  the  least  irritating,  the  mildest  that  our  menu 
contains.  Not  the  total  quantity  of  acid  secreted  constitutes  hyper- 
acidity, but  the  amount  secreted  in  excess  of  what  is  required  for 
combining  with  the  proteids.  For  instance,  a  case  may  show  hyper- 
acidity after  a  simple  Ewald  test-breakfast  of  a  roll  and  a  glass  of 
water,  because  the  acid  secreted  meets  with  nothing  to  combine 
with  and  remains  free,  while  the  same  case  may  show  very  little 
excess  or  normal  acidity  after  the  first  of  our  double  test-meals,  as 
employed  at  the  University  of  Maryland,  consisting  of  beefsteak, 
eggs,  rice,  milk,  and  bread,  because  the  acid,  in  this  instance,  at  once 
enters  into  combination.  The  more  abundant  secretion  of  HCl  is 
more  completely  used  up  when  the  meals  consist  of  a  preponderance 
of  proteid  food  than  when  they  consist  of  carbohydrates.  Therefore, 
the  dietetics  of  these  cases,  as  usually  recommended,  include  the  red 
meats,  venison,  game,  turkey,  eggs,  chocolate,  etc.,  liberally,  a  cer- 


198  DIETETIC   TREATMENT   OP   GASTRIC   DISEASES. 

tain  limitation  of  carbohydrates,  and  the  alkaHne  carbonated  waters. 
In  hyperacidity  and  supersecretion  spices  are  to  be  forbidden,  and 
only  so  much  salt  as  is  indispensable  to  make  the  food  palatable. 
All  acids,  such  as  vinegar  or  lemon-juice,  in  the  food  simply  aggravate 
the  trouble. 

There  are  undoubtedly  different  kinds  of  hyperacidities.  We  feel 
justified  in  distinguishing  two  classes:  (i)  Those  in  which  there  is  a 
preponderance  of  nervous  symptoms  and  fragments  of  the  mucosa 
show  no  increase  in  the  number  of  gland-tubules  or  in  the  oxyntic  or 
acid  cells;  these  cases  are,  then,  of  a  purely  neurotic  type. 

(2)  Secondly,  those  in  which  there  is  an  increase  in  the  number 
of  gland-tubules  or  in  the  oxyntic  cells.  A  simple  neurotic  case 
may  eventually  lead  to  increase  of  oxyntic  cells,  by  the  greater  de- 
mand for  acid  secretion.  There  is  no  hard  and  fast  line  to  separate 
these  classes,  but  they  demand  somewhat  different  treatment  for 
reasons  stated  further  on.  A  number  of  competent  observers  have 
recommended  an  exclusion  of  proteid  and  an  increase  of  the  carbo- 
hydrate foods  in  hyperacidity. 

For,  although  proteid  foods  combine  with  more  HCl  than  any 
other,  they  are  also  the  greatest  stimulants  to  the  secretion  of  acid. 
See  Dujardin-Beaumetz  ("Traitement  des  maladies  de  I'estomac") 
and  von  Sohlern  ("Berlin,  klin.  Wochenschr.,"  xci,  Nos.  20  and  21); 
Kleiner  ("Volkmann's  klin.  Vortr.,"  No.  103);  Rummo  ("Terapia 
clin.,"  1892,  Nos.  10,  II,  12);  V.  Jaksch  ("Zeitschr.  f.  klin.  Med.," 
Bd.  XVII,  1896).  These  writers  argue  that  carbohydrate  food  is 
not  so  irritating  and  calls  forth  much  less  secretion  of  HCl.  W. 
Roux  (" Entwicklungsmechanik  der  Organismen,"  1895)  states  that 
increased  activity  heightens  the  specific  force  of  the  organs,  while 
diminished  activity  lowers  it.  The  existence  of  the  cells  of  the 
organism  depends  upon  their  work ;  those  that  work  most  are  nour- 
ished best  and  grow  strongest.  In  other  words,  the  elements  in 
any  tissue  that  are  incited  to  greatest  activity  and  function  will  gain 
supremacy  ov.er  others  and  increase  in  strength  and  numbers.  The 
deductions  are  not  purely  theoretical,  for  not  only  do  we  find  pro- 
liferation of  acid  cells  in  hyperchlorhydria  to  be  present  in  from 
fifty  to  seventy-five  per  cent,  of  the  cases,  but  in  animals  with  a  high 
acidity  of  HCl  (dog,  fox,  wolf,  etc.,  carnivora)  there  is  a  tremendous 
multiplication  of  acid  cells.  It  seems  logical,  therefore,  that  there 
are  cases  in  which  the  hyperacidity  may,  in  the  long  run,  be  kept 
up  by  a  proteid  diet,  although  for  the  time  being  this  diet  may 


HYPERACIDITY   TREATED    BY   AMYLACEOUS    DIET.  199 

render  the  acidity  less  by  combining  with  the  free  HCl.  Experi- 
ence teaches  that  the  most  annoying  symptoms,  the  gastralgia  and 
pyrosis,  are  promptly  relieved  by  the  proteid  diet,  and  we  shall 
indorse  the  latter  as  most  eminently  proper  in  selected  cases.  When, 
however,  the  symptoms  are  relieved  only  very  briefly,  particularly 
when  the  ratio  of  the  ethereal  to  the  preformed  sulphates  in  the 
urine  is  found  to  become  very  high  under  a  rich  albuminous  diet, 
and  the  indican  increases,  we  advise  a  diet  rich  in  carbohydrates 
and  fats.  The  author  has  analyzed  the  gastric  contents  of  two 
men  who  were  vegetarians  by  principle,  the  average  amount  of  free 
HCl  in  one  being  12.5  after  an  Ewald  test  breakfast;  in  the  other 
the  average  amount  of  free  HCl  was  10.6.  In  a  Japanese  student 
who  had  lived,  according  to  his  own  statement,  almost  exclusively 
on  rice,  milk,  sugar,  and  a  kind  of  Japanese  bread,  the  average 
amount  of  free  HCl  after  an  Ewald  test  breakfast  was  14.6.  See 
Chas.  E.  Simon,  on  "The  Relation  of  Indican  to  Gastric  Diseases" 
("Amer.  Jour.  Med.  Sciences,"  August,  1895).  This  can  be  filled 
by  all  breads  and  articles  made  from  flour,  rice,  peas,  beans,  potatoes, 
the  cereals,  oatmeal,  and  rich  milk  and  butter.  It  is  true  that  in 
some  forms  of  hyperacidity  these  substances  can  be  found  some- 
times six  hours  after  they  are  ingested,  unchanged  in  the  stomach ; 
but  here  the  motility  is  seriously  at  fault.  As  alkalies  must  be 
given  even  with  a  proteid  diet,  they  should,  in  case  the  food  consists 
largely  of  carbohydrates  and  fats,  be  given  immediately  after  meals 
and,  if  need  be,  combined  with  ptyalin  or  diastase  to  hasten  amylo- 
lysis.  It  is  frequently  observed,  that  the  amount  of  free  HCl  be- 
comes less  and  less,  and  the  alkalies  and  artificial  ferments  may  be 
dispensed  with  if  the  amylaceous  diet  is  persisted  in.  This  diet  we 
suggest  particularly  after  the  albuminous  diet  has  failed,  for  there 
are  cases  of  hyperacidity  which  are  undoubtedly  maintained  by  an 
exclusive  proteid  diet.  It  must  not  be  overlooked  that  such  a  thing 
as  a  pure  carbohydrate  diet  does  not  exist,  because  all  articles  of  this 
class  contain  protein,  and  some  very  considerable  quantities  of  it; 
peas,  beans,  and  lentils,  for  example,  contain  more  protein  in  the 
percentage  composition  than  pork,  beef,  ham,  or  fish.  It  is  not  a 
total  exclusion,  but  simply  a  reduction  of  proteid  that  is  practically 
recommejided.  According  to  Pawlow  (' '  Die  Arbeit  der  Vordauungs- 
driisen,"  p.  187),  fats  and  oils  inhibit  the  secretion  of  HCl  by  the 
gastric  mucosa.  We  have  tested  this  on  ten  normal  persons  and  ten 
cases  of  hyperacidity  and  could  confirm  the  observation,  so  that  we 
14 


200  DIETETIC    TREATMENT   OF    GASTRIC    DISEASES. 

now  recommend  butter  and  olive  oil  in  as  large  quantities  as  can  be 
expediently  eaten,  for  cases  of  hyperacidity.  Strauss,  of  Berlin,  has 
found  that  sugars  as  in  candies  reduce  the  secretion  of  HCl. 

All  cases  of  hyperacidity  require  a  certain  amount  of  carbohy- 
drates. It  is  a  matter  of  experience  that  proteid  diet  alone  will 
not  permanently  satisfy  their  cravings.  Flour  and  the  many  articles 
prepared  from  it  are  not  readily  converted  into  dextrin  in  an  ex- 
cessively acid  medium.  It  is  expedient,  therefore,  to  recommend 
dextrinized  flours,  such  as  Avenacia,  Maggi,  and  Kuffeke's  flour. 
The  American  product,  "Horlick's  Food,"  is  a  flour  in  which  the 
wheat  starch  has  been  almost  entirely  converted  into  dextrin  by  malt 
diastase.  It  has  a  high  caloric  value,  and  its  price  is  sufficiently 
moderate  for  a  humbler  practice  when  artificial  flours  seem  indicated. 

Regarding  the  preparation  of  carbohydrates,  we  refer  to  the 
special  lists  given  in  the  text  under  the  various  diseases,  and  to 
Wegele's  "Diatetische  Kiiche."  In  the  hyperacidity  of  ulcer  the 
diet  must  be  of  the  least  irritating  quality,  and  the  coarse-fibered 
meats — beef,  mutton,  lamb,  veal,  venison — are  not  to  be  allowed, 
even  during  the  periods  of  convalescence,  and  when  they  are  finally 
conceded,  they  should  all  be  reduced  to  a  pulpy  (scraped)  form. 

In  sub-  or  anacidity,  when  the  motor  function  is  good,  the  problem 
of  diet  is  not  so  complicated,  because  the  deficient  HCl  can  be  sup- 
plied if  it  is  found  necessary,  and  the  intactness  of  the  peristalsis 
insures  a  good  intestinal  digestion.  As  the  motility  is  the  only 
safeguard  against  malnutrition,  great  care  should  be  taken  to  avoid 
injuring  it  by  overloading  the  organ.  Small  meals  frequently  re- 
peated are  indicated,  consisting  of  very  tender  meat  (in  fine  sub- 
division), soft,  tender  vegetables,  such  as  finely  chopped  spinach, 
cauliflower,  ends  of  asparagus,  puree  of  potatoes,  peas,  beans,  lentils. 
The  fats,  which  are  best  given  in  the  form  of  rich  cream  and  good 
butter,  have  a  high  caloric  value.  Unfortunately,  they  depress  the 
already  deficient  secretion  of  HCl  still  more  in  subacidity.  They 
must  be  forbidden  as  soon  as  it  is  discovered  that  they  cause  gastric 
irritation  by  formation  of  fatty  acids.  The  diet  must  vary  accord- 
ing to  the  cause  of  the  sub-  or  anacidity.  If  it  can  be  ascertained 
that  there  is  no  injury  of  the  glandular  apparatus,  but  simply  an 
inhibition  of  secretion,  the  salty  and  spicy  articles,  even  pepper  and 
ginger,  may  be  advised. 

Such  sub-  or  anacidities  are  improved  by  taking  caviar,  sardelles, 
small  pickled  herrings,  or  anchovies,  before  meals,  because  salt  is  an 


DIETETIC    PREPARATIONS    OF    BEEF.  20I 

approved  stimulant  to  secretion.  In  these  cases  HCl  is  not  only 
supplied  because  of  its  deficiency,  but  also  because  it  is  actually 
curative  in  hastening  the  resumption  of  secretion.  If,  however, 
the  absence  of  HCl  and  ferments  is  due  to  results  of  inflammation 
still  going  on,  all  spices  and  unnecessary  salt  and  foods  containing 
them  must  be  forbidden,  since  they  may  act  as  irritants.  Although 
HCl  is  absent,  it  will  be  found  best  not  to  administer  it  when  it  causes 
symptoms  of  gastric  distress.  In  these  cases,  where  the  mucosa 
is  extremely  sensitive  and  an  atrophic  gastritis  exists,  gastric  diges- 
tion had  best  be  converted  into  an  alkaline  proteolysis  and  amylo- 
lysis  by  supplying  pancreatin.  According  to  recent  experiments 
(Rachford,  "Amer.  Jour,  of  Physiol.,"  vol.  ii)  sodium  bicarbonate 
retards  pancreatic  digestion,  and  hence  its  addition  to  pancreatin  is 
not  called  for.  In  these  extreme  cases  of  sub-  or  anacidity  it  is 
sometimes  found  that  hydrochloric  acid  gives  pain  and  even  causes 
emesis.  Meats  that  are  given  in  anacidity  must  not  be  too  fresh, 
but  properly  seasoned  and  very  tender;  they  must  be  thoroughly 
cooked  in  a  steam  broiler  until  they  almost  fall  apart  into  the  primi- 
tive muscle-bundles.  A  practical  way  is'  to  rub,  cut,  or  scrape  the 
meat  prior  to  cooking  it.  Finally,  if  in  addition  to  the  anacidity 
one  has  reason  to  believe  that  duodenal  digestion  is  also  disturbed 
(from  chronic  duodenitis,  occlusion  of  the  pancreatic  or  bile-duct, 
or  from  catarrh,  or  carcinoma  of  the  duodenum,  pancreas,  gall- 
bladder, or  liver),  then  the  administration  of  meat-powders  and  beef 
peptones  is  in  order.  These  substances,  which  are  really  albumoses, 
though  capable  of  satisfying  the  requirements  of  metabolism,  are 
not  palatable  and  are  relatively  expensive.  The  peptones  most  fre- 
quently used  in  Germany  are  those  of  Kemmerich,  Denayer,  and 
Maggi.  Ewald  and  Gumlich  ("Berlin,  klin.  Wochenschr.,"  1890,  No. 
44)  have  investigated  the  qualities  of  a  "peptone  beer,"  and  found 
it  quite  nutritious.  Boas  speaks  favorably  of  the  American  product 
"Mosquera"  Julia  Beef  Meal.  Professor  R.  H.  Chittenden  (in  a 
report  to  the  Philadelphia  County  Medical  Society,  May,  1891)  has 
given  the  results  of  his  analysis  of  American  beef  products,  which 
are  found  in  the  following  table : 


202 


DIETETIC   TREATMENT   OF   GASTRIC   DISEASES. 


PERCENTAGE  COMPOSITION  OF  BEEF  PRODUCTS,  ANALYZED  1891, 


Constituents. 

h 

u 

< 

X  w 
W  w 

<«« 

« 

X  w 

is 

Pi  < 

w  u 
23 

Is 
Si 

w 

's? 

>  w 

w 
z 
z 

> 
0 

M 

M  0 

^5 

X  D 
0  J 

zoo 

GO  Z 

Water  (at  1 10°  C), 

20.06 

14-03 

60.31 

57.88 

81.09 

83-99 

39.58 

6.80 

6.68 

Solid     matter     (at 

110°  C),    .    .    . 

79-94 

85.97 

39-69 

42.12 

18.91 

16.01 

60.42 

93.20 

93-32 

Soluble  in  water,  . 

50.40 
10.02 

48.14 
45.06 

31.26 
62.06 

Insoluble  in  water, 

0 

0 

0 

0 

0 

0 

Inorganic  constitu- 

ents,   ..... 

24.04 

28.29 

11.30 

17-52 

1.02 

0.66 

13-52 

5.08 

4-23 

Pliosphoric      acid 

(PA),  •  •  •  ■ 

9-13 

7.28 

4.00 

3-94 

0.03 

0.09 

3-91 

1.40 

I-7I 

Fat,    ether   extrac- 

tives,   

0.91 

1.27 

0.78 

0.85 

1.49 

0.27 

1.29 

2-95 

13.60 

Soluble    in    80  per 

cent,  alcohol 

55-72 
9-52 

67.92 
8.80 

29-15 

2.68 

35-08 
3-25 

34-IO 
7.38 

Total  nitrogen. 

2.43 

2.29 

4.42 

12.36 

Nitrogen  of  insolu- 

ble matter,     .    . 

1.46 

3-25 

7.65 

Insoluble      proteid 

matter,    .... 

9.12 

20.30 

47.81 

Soluble  albumin 

coagulable        by 

heat, 

0.06 

0.68 

0-55 

0.47 

13.98 

14.29 

0 

0 

0 

Soluble  albumoses, 

0 

0 

0 

0 

0 

0 

0 

5-44 

11.09 

Peptone,     .... 

0 

0 

0 

0 

0 

0 

0 

1.87 

18.34 

Total  proteid  mat- 

ter   available    as 

nutriment,       .    . 

0.06 

0.68 

0.55 

0.47 

13.98 

14.29 

9.12 

27.61 

77.24 

Nutritive   value   as 

compared      with 

fresh     lean    beef 

(leanbeef=ioo). 

0.30 

3-50 

2.80 

2.40 

72.40 

74.00 

47-20 

14.30 

400.00 

Armour  &  Company,  of  Chicago,  manufacture  a  valuable  product 
which  is  called  "Vigoral,"  containing  sixty-eight  per  cent,  albumi- 
noids. It  is  a  saturated  solution,  or  rather  suspension,  of  pure 
powdered  beef  in  beef  extract.  These  substances  readily  decom- 
pose and  should  be  tested  as  to  their  freshness.  So  the  table  of 
Chittenden's  comparisons  is  valuable  only  to  show  the  superiority 
of  foods  containing  the  beef  in  powder  or  insoluble  form,  to  the  ex- 
tracts, which  represent  only  the  soluble  salts  of  the  beef  and  very 
little  of  the  nitrogenous  constituents — rarely  more  than  eight  per 
cent. 

The  Mosquera  beef  meal  is  a  product  that  undoubtedly  has  an 
exceptionally  high  nutritive  value,  the  total  proteid  matter  avail- 
able  as  nutriment   being   77.24   per  cent.     It   also  contains    13.60 


DIETETICS    OF    ATONY    AND    DILATATION.  203 

per  cent,  fat,  11.09  per  cent,  soluble  albumoses,  and  18.34  per  cent, 
of  peptone.  With  Chittenden's  authority  for  this  analysis,  and  our 
own  experience  as  to  its  easy  digestibility  and  perfect  absorption, 
this  product  commands  an  important  place  in  our  dietary  for  sub- 
or  anacidity  and  gastric  atrophy,  particularly  when  associated  with 
intestinal  disease.  The  juice  of  the  pineapple  contains  a  proteo- 
lytic ferment,  thus  adapting  this  fruit  for  the  treatment  of  cases 
where  no  gastric  juice  is  secreted.  For  its  digestive  effect  only  the 
juice  of  the  fresh  fruit  should  be  swallowed,  and  the  fiber  removed 
from  the  mouth.  By  boiling  the  pineapple  the  proteolytic  ferment 
is  destroyed. 

When  atony  or  pronounced  dilatation  accompanies  any  gastric  dis- 
ease, particularly  those  already  referred  to,  the  dietetic  manage- 
ment is  most  important.  Weakening  and  loss  of  motility  are  among 
the  most  serious  affections  of  the  organ,  and  in  the  gravity  of  their 
consequences  outweigh  any  disturbance  of  secretion.  Motor  in- 
sufficiency may  supervene  upon  any  gastric  disease.  As  a  rule, 
the  chronic  affections  rarely  become  manifest  until  the  motility  is 
disturbed;  that  is,  until  the  muscular  tonus  relaxes.  Many  times 
a  co-existing  secretory  or  organic  disease  is  the  cause  of  the  dilata- 
tion; for  instance,  it  is  generally  admitted  that  hyperacidity  can 
produce  spasm  of  the  pyloric  sphincter,  which  the  gastric  peristalsis 
will  be  unable  to  overcome. 

In  the  section  on  Motor  Insufficiency,  in  the  third  (clinical)  part 
of  this  work,  the  etiology  of  this  affection  will  be  fully  considered. 

When  ingesta  remain  in  the  stomach  longer  than  normally,  fer- 
mentation, gas-formation,  and  distention  eventually  supervene, 
causing  stasis  in  the  muscular  layer  and  dilatation  (Naunyn, 
"Deutsches  Arch.  f.  klin.  Med.,"  1882,  Bd.  xxxi).  In  dilatation 
proper — the  deciding  sign  of  which  is  presence  of  ingesta  in  the  stom- 
ach in  the  morning  after  a  test-meal  taken  twelve  hours  previously 
— we  must,  from  a  dietetic  as  well  as  from  a  therapeutic  standpoint, 
distinguish  between  the  myasthenic,  atonic  form  due  to  simple  re- 
laxation of  the  muscularis,  and  the  obstructive  form  due  to  pyloric 
or  duodenal  stenosis. 

In  the  first  variety  dietetic  and  other  treatment  may  effect  a  cure. 
In  the  stenotic  types  little  beyond  transient  improvement  must  be 
expected,  except  when  the  obstacle  (cicatrix,  carcinoma,  hyper- 
trophied  pylorus,  gall-stones,  peritoneal  adhesions,  etc.)  can  be 
removed  permanently  or  temporarily,  or  where  a  new  route  can  be 


204  die;te:tic  treatment  of  gastric  diseases. 

devised  for  the  passage  of  the  chyme.  Here  abdominal  surgery 
asserts  itself,  and  gastro-enterostomy  has  thus  far  produced  the 
best  results.  (See  chapter  on  Operative  Treatment  of  Gastric  Dis- 
eases.) 

The  dietetic  management  of  dilatation  will  have  regard  not  only 
to  the  injured  muscular  tonus,  but  also  to  the  secretory  or  organic 
disease  with  which  it  may  be  associated.  For  example,  if  it  is  asso- 
ciated with  chronic  gastritis,  the  diet  must  be  that  for  this  disease 
and  dilatation;  and  if  it  is  combined  with  hyperacidity,  the  diet  is 
the  one  devised  for  this  trouble  and  dilatation.  As  the  funda- 
mental thing  in  dilatation  is  to  prevent  burdening  of  the  muscu- 
laris,  the  diet  must  be  as  light  in  weight  as  possible,  and  especially, 
as  far  as  practicable,  exclude  liquids,  for  these  are  not  only  all  heavy, 
but  are  not  at  all  absorbed  from  the  stomach  (excepting  alcohol). 
The  requisite  amount  of  water  is  best  given  by  high  sigmoid  enemata : 
^  of  a  liter,  slightly  warmed,  two  or  three  times  a  day.  In  this 
manner  a  water  impoverishment  can  be  prevented  (see  Wegele, 
"Die  atonische  Magenerweiterung  u.  ihre  Behandlung").  An  ab- 
solutely dry  diet  was  suggested  by  van  Swieten,  Chomel  ("Les  Dys- 
pepsies,"  Paris,  1857),  and  Fossagrives,  but  its  strict  execution,  as 
was  developed  by  Schroth,  is  impracticable,  since  fully  developed 
dilatations  require  months,  even  years,  of  strict  dieting,  which,  if 
followed  out  on  these  lines,  would  inevitably  produce  dangerous 
drying  out  of  the  organs  (Kussmaul,  "2ur  Behandl.  d.  Magenerweit.," 
"Deutsch.  Arch.  f.  klin.  Med.,"  Bd.  vi). 

Although  it  is  not  a  dietetic  therapy,  yet  lavage  must  be  men- 
tioned here.  If  large  masses  of  decomposed  food  are  vomited,  the 
stomach-tube  is  indispensable.  Milk  diet,  used  exclusively,  aggra- 
vates the  symptoms  without  exception.  Should  the  vomit  or  test- 
meals  reveal  that  carbohydrates  habitually  disagree  and  ferment, 
an  exclusive  beef-  or  meat-diet  for  a  few  weeks  is  rational,  and  is 
followed  by  less  distention  (Minkowski). 

In  very  severe  and  extreme  cases  of  dilatation  one  may  be  com- 
pelled to  feed  exclusively  by  rectal  enemata,  for  the  preparation  of 
which  we  refer  to  the  paragraph  on  that  subject.  Soups  and  drinks 
during  meals  must  be  avoided.  Great  thirst  can  be  quenched  by 
taking  small  pieces  of  ice  into  the  mouth.  Patients  that  are  being 
treated  with  lavage  may  be  permitted  to  quench  their  thirst  before 
the  evacuation.  Moritz  has  shown  that  solid  food  is  retained  longer 
than   semisolid;   the    latter   form    is,  therefore,    preferable.     Meats 


DIET   IN    CARCINOMA.  205 

are  given  best  in  scraped  or  finely  chopped  state,  and  must  be  of  the 
red  varieties  and  free  from  fat.  Meat  dumpHngs  or  balls,  hash  of 
fresh  beef  or  lamb,  Mosquera  beef-powder,  Valentine's  or  Wyeth's 
juice,  or  Wiel's  beef-jelly,  are  adapted  to  dilatations  in  which  secre- 
tion is  preserved.  When  gastric  digestion  is  much  lowered  the 
cereal  and  leguminous  products  are  useful.  We  recommend  gruels 
made  from  arrowroot,  tapioca,  rice,  sago,  cerealin,  strained  oatmeal, 
after  which  we  are  accustomed  to  advise  some  form  of  diastase, 
either  the  taka  diastase  or  malt  extract.  Aleuronat  flour,  contain- 
ing much  digestible  albumin  (prepared  by  Dr.  Hundhausen,  Hamm, 
Westphalia,  Germany),  and  the  soup  meals  of  C.  H.  Knorr  (Heil- 
bronn,  Germany)  are  of  use  when  prepared  according  to  our  dietetic 
directions.  To  be  digestible,  even  for  healthy  stomachs,  all  legumi- 
nous foods  must  be  cooked  a  long  time.  For  gastric  sufferers  they 
must  be  used  only  in  a  condition  of  very  fine  subdivision,  and  partial 
dextrinization  of  their  starch,  rendering  it  more  soluble.  Besides 
the  products  of  this  character  just  mentioned,  we  have  used  the 
Liebig  malto-leguminose  (prepared  by  William  Roth,  Jr.,  in  Stutt- 
gart), and  the  biscuit-leguminose  (Theodor  Fimpe,  in  Magdeburg). 
The  firm  of  Hartenstein  &  Company  (Chemnitz,  Germany)  prepare 
several  good  leguminous  flours.  The  Farbenfabriken  of  Elberfeld, 
Germany,  produce  the  valuable  mixture  of  albumoses  known  as 
somatome,  which  can  be  obtained  in  the  form  of  chocolate,  cocoa, 
and  biscuit.  Further  references  in  Penzoldt  and  Stintzing's  "Hand- 
buch  d.  Therapie,"  vol.  iv,  pp.  256-258. 

The  collection  of  dietaries  will  contain  menus  for  gastric  atony 
and  dilatation  (i)  with  loss  of  secretions  or  anacidity;  (2)  with  nor- 
mal or  augmented  secretions;  (3)  with  serious  stenotic  symptoms, 
In  severe  cases  of  the  latter  type  even  the  most  sparing  diet  by  the 
mouth  will  be  impossible,  and  as  a  last  resource  we  must  fall  back 
on  nutritive  rectal  enemata.  Sometimes  after  a  week  to  ten  days  of 
rectal  alimentation,  the  diseased  condition  becomes  so  improved  that 
partial  mouth-feeding  may  be  resumed. 

The  diet  in  the  various  types  of  carcinoma  coincides  with  that 
of  motor  insufficiency  and  dilatation  whenever  the  neoplasm  is  caus- 
ing the  stenosis.  In  carcinoma  of  those  portions  which  do  not  form 
an  obstacle  to  the  exit  of  the  chyme,  and  where  the  motility  is  good, 
the  patient's  appetite  must  be  stimulated  as  much  as  possible  by 
strychnin,  HCl,  bitter  tonics,  condurango,  etc.,  and  nothing  for- 
bidden, as  the  physician  must  be  satisfied  if  the  patients  eat  any- 


206  DIETETIC    TREATMENT   O'P    GASTRIC    DISEASES. 

thing.  As  chronic  gastritis  is  always  present  even  in  these  cases, 
the  diet  list  as  given  for  this  disease  is  advisable. 

In  cancer  arising  on  the  basis  of  old  gastric  ulcers,  the  ulcus  car- 
cinomatosum,  there  is  often  a  pronounced  hyperacidity  which,  natur- 
ally, is  best  met  by  the  diet  recommended  for  augmented  gastric 
secretion,  provided  the  stenosis  permits  it. 

Where  the  stenosis  is  at  the  cardia  the  matter  of  proper  alimenta- 
tion becomes  difficult. 

So  long  as  the  stenosis, — no  matter  from  what  cause, — can  be  kept 
open  by  bougies  and  sounds,  a  highly  nourishing  liquid  diet  of  milk, 
eggs,  beef -jelly,  beef-meal,  peptone,  nourishing  soups  containing 
somatose,  and  wines  are  indicated.  In  rare  cases  we  have  seen  life 
prolonged  by  allowing  the  esophageal  tube  to  remain  in  situ  and  feed- 
ing through  it  every  two  to  three  hours.  lyCyden  (lyCyden-Renvers, 
"Deutsche  med.  Wochenschr.,"  1887,  No.  50)  and  Gersunny  ("Wien. 
med.  Wochenschr.,"  1887,  No.  43)  have  strongly  indorsed  this  pro- 
cedure for  esophageal  strictures  of  carcinomatous  origin.  After 
the  stenosis  is  no  longer  passable,  and  gastrostomy  becomes  necessary, 
in  order  that  nutrition  may  be  carried  on  through  the  gastric  fistula. 
According  to  Friedenwald's  studies  on  salivary  digestion  it  would 
be  logical  to  advise  these  unfortunates  to  chew  their  food  first,  and 
removing  it  from  the  mouth,  insert  it  through  the  fistula.  But 
where  this  is  objected  to,  it  is  expedient  to  add  fifteen  grains  of  pty- 
alin  to  the  food,  which  must  always  be  liquid  or  in  the  form  of  paste, 
soup,  or  gruel.  Finally,  when  gastrostomy  can  not  be  done,  or  per- 
mission to  perform  it  is  refused,  the  only  way  to  nourish  the  patient 
is  by  rectal  enemata.  So  it  is  evident  that  the  symptoms  and  dietetic 
management  of  carcinoma  vary  greatly  according  to  its  location. 
In  September,  1897,  we  had  under  observation  a  patient  who  had  a 
gastric  tumor,  which  as  far  as  could  be  palpated  was  about  four 
inches  long  and  two  inches  wide.  There  has  been  no  evidence  of 
HCl  secretion  for  over  a  year,  but,  as  the  motility  is  very  good, 
there  is  no  lactic  acid  formation.  The  Oppler-Boas  bacillus  has  been 
repeatedly  found  in  the  gastric  contents  when  there  was  temporary 
food  retention.  Permission  for  operation  was  refused.  Still,  this 
patient,  with  an  undoubted  carcinoma,  gained  twelve  pounds  in  six 
weeks,  and  had  no  subjective  complaints  while  in  our  sanitarium 
for  digestive  diseases. 

With  anacidity  and  a  fair  peristalsis  a  carbohydrate  diet  is  applic- 
able to  carcinoma,  but  when  HCl  is  well  tolerated  the  various  meats 


DIET    IN    GASTRIC    ULCER.  207 

must  not  be  forbidden.     Of  these,  Boas  prefers  the  meat  from  various 
fishes.     Where  HCl  is  not  well  tolerated,  pancreatin  is  in  place. 
Lavage  can  not  be  avoided  when  much  fermentation  and  signs  of 
dilatation  are  marked;  in  case  these  signs  are  very  annoying,  a  few 
days  of  exclusive  meat  diet  or  of  rectal  feeding  may  be  necessary 
to  restore  somewhat  of  the  lost  gastric  tonicity.     Long  before  py- 
loric stenosis  is  complete,  the  case  should  be  transferred  to  the  sur- 
geon, as  the  resorption  from  the  stomach  itself,  even  if  it  were  normal, 
is  insufficient  to  maintain  life.     Those  materials  that  are  readily 
absorbed  from  a  healthy  stomach,   such   as  albumoses,   peptone, 
glucose,  and  maltose,  etc.,  are  given  in  these  cases.     There  is  little 
evidence,  however,   of  their  being  absorbed.     The  good  effects  of 
gastro-enterostomy  consist  not  only  in  the  entrance  made  for  the 
food  into  the  intestine,  whereby  better  digestion  becomes  possible, 
but  also  in  an  improvement  in  the  inflammatory  process  around  the 
neoplasm,  which  is  no  longer  kept  in  continual  irritation  by  stag- 
nating, fermenting  masses  of  food  in  constant  contact  with  it.     The 
main  reason  why  operations  do  not  bring  as  much  relief  and  im- 
provement as  is  expected  is  to  be  sought  in  the  delay  in  performing 
them. 

The    Dietetics    of    Gastric    Ulcer    and    Erosions.— There   are 
three  types  of  gastric  ulcer  which  demand  a  varying  or  separate 
dietetic  treatment.     These  are:  (i)  Light  attacks  with  pain,  hyper- 
acidity, and  pyrosis,  but  no  vomiting  of  blood.      (2)  Serious  cases 
that  have  had  hematemesis,  and  still  have  signs  of  it  at  the  time  of 
presentation.      (3)  Old,  chronic,  frequently  relapsing  gastric  ulcers. 
There  are  forms  that  run  a  latent  course,  void  of  symptoms  until 
a  sudden  severe  hemorrhage  surprises  the  patient  and  physician, 
and  possibly  terminates  the  case.     Erosions  which  have  no  great 
extension  laterally  nor  toward  the  depth,  and  can  be  recognized  by 
fragments  of  mucosa  found  in  the  wash-water,  yield  very  readily  to 
an  exclusive  diet  of  milk  combined  with  rest.     During  the  gastric 
hemorrhage  we  advise  that  nothing  at  all  be  given  by  the  mouth,  not 
even  water,  nor  ice  pills,— absolutely  nothing ;  but  absolute  rest,  a 
hypodermic  injection  of  301TL  of  ergotol,  and,  if  pain  and  restlessness 
are  marked,  i  of  a  gr.  of  morphin  sulphate  hypodermically,  and  a 
small  ice-bag  placed  over  the  epigastrium.     Wiel  claims  to  have  ar- 
rested gastric  hemorrhage  by  lavage  with  cold  (io°  C.)  or  hot  (42°  C.) 
water.     Such  treatment  in  profuse  bleeding  at  first  impresses  one  as 
hazardous.     But  the  author  has  had  very  good  results  from  lavage 


2o8  DIETETIC   TREATMENT    OF    GASTRIC    DISEASES. 

with  ice-water  in  arresting  severe  gastric  hemorrhage.  (See  Ewald, 
"Philadelphia  Med.  Jour.,"  vol.  ii,  p.  334.)  This  course  has,  in  a 
very  large  number  of  cases,  been,  as  a  rule,  very  satisfactory. 

If  there  is  much  weakness  we  use  the  Boas  or  Ewald  nutritive 
enemata  on  the  day  of  and  following  the  hematemesis ;  but  if  the 
pulse  is  good  w^e  dispense  with  them.  On  the  day  following  the 
hemorrhage,  milk  in  teaspoonful  doses  is  given  every  half  hour ;  egg- 
albumen,  if  it  is  taken  willingly,  is  more  fitting,  as  it  combines  with 
a  larger  amount  of  HCl,  and  when  diluted  it  does  not  stimulate 
secretion. 

Brandy  and  wine  are  to  some  extent  irritating  to  ulcers  and  excite 
more  secretion ;  they  are  accordingly  not  given  except  there  be  great 
prostration.  On  the  third  day  it  will  be  safe  to  proceed  to  carr^dng 
out  a  Leube  rest  cure,  with  the  consecutive  order  of  diet  suggested 
by  him  or  the  diet  lists  proposed  by  Penzoldt,  both  of  which  present 
four  different  groups  of  food-materials.  Beginning  with  the  simplest 
and  most  digestible,  they  gradually  lead  up  to  a  more  consistent 
ordinsLVj  household  menu. 

Each  of  these  four  diet  orders  must  be  persisted  in  from  one  week 
to  ten  days.  Penzoldt's  and  Leube's  diet  orders,  together  with  our 
explicit  diet  lists  for  various  stages  of  gastric  ulcer,  will  be  appended. 
The  principle  underlying  all  treatment  by  food  in  these  cases  is  to 
secure  the  greatest  amount  of  rest  and  such  substances  as  will  com- 
bine with  the  largest  amount  of  HCl  and  relieve  the  hyperacidity. 
In  a  number  of  cases  of  ulcer  we  have  found  that  an  amylaceous  diet 
was  retained  better  and  caused  less  pain  than  scraped  beef  or  soft  eggs. 
It  is  advised  on  the  same  principles  as  stated  on  pages  197-199. 

In  chronic  and  frequently  recurring  cases  of  ulcer,  McCall,  Ander- 
son ("Brit.  Med.  Jour.,"  May  10,  1890),  and  H.  B.  Donkin  ("The 
Lancet,"  vSeptember  27,  1890)  have  had  excellent  results  from  total 
exclusion  of  the  stomach  from  digestion,  by  feeding  with  rectal 
enemata  altogether;  some  of  their  cases  were  nourished  in  this  way 
for  twenty-three  days.  Riegel  ("Zeitschr.  f.  prakt.  Aerzte,"  1890, 
No.  2)  speaks  enthusiastically  of  this  treatment  in  stubborn  cases 
of  ulcer,  and  Boas  reports  ten  cases,  all  of  which  but  one  were  cured 
by  this  method,  by  giving  three  to  four  of  his  nutritive  enemata 
daily  for  fourteen  days.  We  have  a  personal  experience  of  twenty- 
five  persistent  cases  of  ulcer  treated  in  this  manner,  together  with 
nitrate  of  silver,  bismuth  subnitrate  internally,  and  rest  cure,  and 
are  disposed  to  look  upon  the  treatment  with  great  favor.      (See 


DIET    IN    SENSORY    NEUROSES.  209 

Gros,  "Traitement  de  Malad.  de  Testomac  par  la  cure  de  Repos 
absolu,"  etc.)  An  ulcer  must  not  be  considered  cured  until  there 
is  no  more  epigastric  pain  on  pressure  and  the  patient  gains  weight 
(Gerhardt). 

The  treatment  of  the  sensory  gastric  neuroses,  to  be  effective, 
must  combine  a  number  of  remedial  agents  with  diet. 

Hyperesthesia,  gastrodynia,  or  gastralgia,  and  neurasthenia  gastrica 
are  morbid  states,  the  treatment  of  which  must  be  largely  directed 
to  the  central  nervous  organs.  The  same  must  be  said  of  the  motor 
neuroses:  Cardiospasm  and  pylorospasm,  nervous  vomiting,  rumina- 
tion, KussmauV s  peristaltic  unrest,  incontinence  of  the  cardia  and  of 
the  pylorus.  These  diseases  demand  electric,  hydropathic,  climatic, 
and  medicinal  measures,  with  special  massage. 

A  very  careful  investigation  into  possible  causative  constitutional 
morbid  states  (anemia,  gout,  rheumatism,  tuberculosis,  chlorosis, 
uric  acid  diathesis)  will  often  reveal  a  removable  underlying  etio- 
logical foundation.  Fliess  has  reported  cases  of  gastralgia  and 
vomiting,  emanating  reflexly  from  the  nasal  mucosa,  and  has  cured 
them  by  local  treatment  ("Neue  Beitr.  z.  Klinik  u.  Therapie  d. 
Nasal-Refiexneurose").  A  case  of  intense  gastralgia  that  came  on 
particularly  at  night  was  cured  by  mercurial  inunctions;  the  author 
having  suspected  syphilis,  although  this  was  denied  by  the  patient. 
In  a  similar  way  attention  to  gynecological  disorders  in  the  female 
and  genito-urinary  diseases  in  the  male  has  led  to  the  cure  of  dis- 
tressing nervous  dyspepsias.  In  the  gastric  neuroses  of  motor  or 
sensory  type  the  diet  must  be  based,  as  in  all  previous  diseases,  as 
far  as  is  expedient,  upon  the  state  of  the  secretion  and  motility. 
When  the  general  nutrition  is  disturbed,  the  plan  of  treatment  most 
generally  adopted  is  a  fattening  rest  cure  according  to  the  principles 
laid  down  b}^  Weir  Mitchell  and  Playfair.  This  treatment,  though 
not  universally  applicable,  is  the  one  most  to  be  employed  in  nervous 
vomiting  of  hysterical,  anemic,  and  chlorotic  origin,  and  in  stubborn 
cases  of  anorexia  and  gastralgia.  It  is  somatic  and  psychical  at  the 
same  time.  We  have  had  ample  opportunity  to  test  the  dietetic 
part  of  this  treatment  as  it  has  been  developed  by  Burkart  in  Ger- 
many ("Volkmann's  klin.  Vortrage,"  No.  245).  And  cases  of  the 
types  described  have,  in  our  local  sanitarium  and  in  the  various 
hospitals  with  which  the  author  is  connected,  been  completely  cured. 
Of  course,  organic  changes  in  the  digestive  organs  render  the  proper 
nutrition  impossible. 


2IO  DIETEJTIC   TREATMENT   OF    GASTRIC    DISEASE^S. 

Contraindications  to  fattening  cures  are:  Cerebral  excitation  or 
depression;  hysteria,  with  uncontrollable  vomiting;  and  visceral 
neuralgias,  which  are  expressions  of  sympathetic  nerve  diseases. 

The  best  results  with  Weir  Mitchell's  rest  and  fattening  cures  are 
obtained  in  neurasthenic  or  hysterical  anorexia  with  much  emacia- 
tion, but  where  there  is  no  organic  digestive  disease.  Wherever  the 
nervous  dyspepsia  is  accompanied  by  gastritis,  atony,  or  dilatation, 
fattening  cures  may  easily  cause  pain,  pressure,  vomiting,  and  diar- 
rhea ;  so  that  if  such  cures  are  attempted  because  everything  else  has 
been  tried,  one  must  be  cautious  not  to  persist  in  systematic  intro- 
duction of  large  amounts  of  food,  even  in  divided  portions,  as  the 
frequently  repeated  small  portions  may  accumulate  when  gastric 
atony  exists,  etc.,  and  aggravate  the  symptoms. 

Burkart  begins  with  lOO  gm.  of  milk  with  Zwieback  every  two 
hours,  and  increases  it  so  that  two  to  three  liters  of  milk  per  day 
are  taken  after  fourteen  days  of  treatment.  The  milk  may  be 
flavored  with  sugar,  cocoa,  tea,  lime-water,  or  salt,  according  to 
taste ;  and  after  a  few  days  other  articles  of  diet  are  cautiously  added. 
We  give  Burkart's  complete  menu  among  our  diet  tables. 

Neurasthenia  gastrica  (Ewald),  or  the  nervous  dyspepsia  of  Leube, 
when  it  occurs  in  males,  is,  in  our  experience,  not  benefited  by  the 
methods  of  Weir  Mitchell  or  Burkart.  Here  more  than  ever  the 
physician  must  endeavor  to  remove  the  cause  if  possible  (excess  in 
tobacco,  overwork,  uric  acid  diathesis,  sexual  indulgence).  A 
definite  diet  can  not  be  given,  because  there  are  rarely  two  cases 
alike;  the  dietetic  treatment  of  nervous  dyspepsia  is  difficult,  the 
strictest  individualization  is  requisite. 

The  prognosis  as  regards  perfect  recovery  is  doubtful.  An  attempt 
with  the  lycube  or  Penzoldt  order  of  dieting  is  not  only  rational,  but 
sometimes  productive  of  lasting  improvement. 

The  Indications  for  Predigested  Foods :  Peptones,  Albu- 
moses,  Dextrose,  etc. — The  idea  of  supplying  foods  that  would 
replace  the  lost  digestive  function  of  the  stomach  or  by  presenting 
them  in  an  absorbable  form  that  would  spare  the  work  which  it  had 
become  incapable  of  performing,  was  suggested  by  the  recognition  of 
diseases  that  tended  to  destroy  the  glandular  apparatus,  or  caused 
emesis  of  the  ingested  food. 

In  such  instances  in  which  the  amount  of  albuminous  foods  that 
can  be  taken  is  very  small,  the  question  has  been  raised  whether 
peptones  are  able  to  equalize  the  deficit  of  albumin  requirement. 


USE  OF  PREDIGESTED  FOODS.  211 

As  a  certain  amount  of  albuminous  food  is  indispensable  to  life, 
whenever  the  quantity  ingested  sinks  below  the  so-called  thresh- 
old value  of  albumin  ("Schwellenwerth"),  health  begins  rapidly  to 
decline.  Deiters  has  shown  (von  Noorden,  "Beitr.  z.  Lehre  v. 
Stoffverlust  d.  gesund.  u.  krank.  Menschen,"  Heft  i,  1892)  that  even 
when  the  amount  of  albumin  ingested  sinks  below  the  threshold 
value,  peptones  and  albumoses  (Denayer's  mixture)  are  capable  of 
maintaining  the  body  in  nitrogenous  equilibrium.  Kuhn  confirmed 
this  observation  in  Riegel's  laboratory  with  regard  to  an  albumose 
mixture  selling  under  the  name  of  somatose;  so  that  we  may  con- 
clude that  these  products  can  replace  food-albumin  for  a  time  at 
least;  still,  we  doubt  very  much  whether  it  is  expedient  or  neces- 
sary to  give  peptones  and  albumoses  in  larger  quantities.  Their 
expensiveness  would  be  no  serious  objection  if  the  advantages  of 
their  use  were  very  obvious. 

In  secretory  insufficiency  of  the  stomach  it  is  well  known  that  the 
proteolytic  power  of  the  intestine  will  utilize  most  of  the  unaltered 
proteid. 

Even  where  the  stomach  is  excluded  from  digestion  entirely, 
albumin  is  used  up  to  a  sufHcient  degree  (Ogata,  "Arch.  f.  Anat.  u. 
Physiol.,"  1883,  S.  89).  Loss  of  peptic  function,  therefore,  does 
not  prevent  sufficient  utilization  of  albumin.  There  is  an  apparent 
advantage  in  the  bland  and  unirritating  quality  of  albumoses,  but 
certainly  this  is  possessed  also  by  certain  undigested  foods  (milk, 
egg-white).  Peptones  and  albumoses  are  not  absorbed  more  readily 
when  ingested  ready-formed,  than  when  they  are  first  developed 
from  albumin  in  the  stomach  (Cahn,  "Die  Verwendung  d.  Pepton 
als  Nahrungsmittel,"  "Berlin,  klin.  Wochenschr.,"  1893,  No.  24). 

They  are  said  to  produce  diarrhea;  but  to  establish  this  fact,  the 
quantity  of  artificial  peptone  and  the  amount  of  nitrogen  in  the 
remaining  ingesta  must  be  considered  together,  for  the  diarrhea  may 
be  due  to  excess  of  nitrogenous  food,  which  may  be  given  unknow- 
ingly, since  it  is  impossible  to  determine  the  total  nitrogen  ingested, 
except  by  quantitative  analysis. 

As  an  indication  for  the  use  of  predigested  foods,  we  may  state 
the  conditions  where  the  albumin-dissolving  power  of  the  stomach 
is  permanently  reduced  or  lost,  where  the  amount  of  meat-  and 
egg-ingestion  becomes  insufficient  because  of  efforts  necessary  to 
avoid  mechanical  irritation.  If  duodenal  digestion  is  also  deranged, 
the  indication  becomes  more  urgent.     When  the  secretory  function 


212  DIETETIC    TREATMENT    OE    GASTRIC    DISEASES. 

is  lost,  but  the  motility  preserved,  the  vicarious  intestinal  proteo- 
lysis will  digest  sufficient  proteid.  When  peristalsis  is,  however, 
also  lost,  then  the  administration  of  peptones  is  of  no  benefit,  for 
we  agree  with  Cahn  {loc.  cit.)  that  in  gastrectasia  dependent  upon 
pyloric  stenosis,  peptones  are  not  absorbed,  but  remain  in  the  stom- 
ach just  as  water  does.  Riegel  (loc.  cit.,  p.  241)  considers  this 
deduction  of  Cahn's  as  erroneous,  because  von  Mehring  has  shown 
that  the  stomach  does  absorb  peptone.  To  this  we  would  reply, 
that  von  Mehring  did  not  experiment  upon  dilatations  dependent 
upon  stenosis,  but  upon  normal  stomachs. 

In  his  experiments  Cahn  found  that  peptone  causes  an  increased 
flow  of  the  gastric  juice,  and  suggested  that  therefore  it  should  not 
be  given  in  hyperacidity  and  hypersecretion,  in  which  evidently  it 
is  quite  unnecessary,  as  in  these  secretory  abnormalities  meat  and 
e.gg  are  digested  excellently.  In  ulcer,  albumoses  may  find  tempor- 
ary usefulness  because  of  their  unirritating  qualities,  which,  of  course, 
would  be  counterbalanced  by  their  effect  in  increasing  the  HCl,  should 
Cahn's  conclusion  prove  true.  Pure  peptone  represents  a  proteid 
not  coagulable  by  boiling  nitric  acid,  acetic  acid,  ferrocyanide  of 
potash,  nor  ammonium  sulphate.  Such  a  peptone  has,  in  our  ex- 
perience, no  field  of  usefulness  in  practical  dietetics.  It  is  an  irritant 
to  the  mucosa  of  the  digestive  canal  and  has  an  intolerably  bitter 
taste. 

In  conclusion,  we  may  state  our  personal  custom  in  the  use  of 
these  substances.  Whenever  the  ingestion  of  albumin  in  the  food 
becomes  insufficient,  or  even  where  it  is  ingested  in  sufficient  amounts 
for  a  healthy  individual,  but  owing  to  some  consuming  disease,  such 
as  carcinoma  (not  hindering  peristalsis),  tuberculosis,  etc.,  it  can 
not  cover  the  nitrogen  equilibrium,  in  the  amounts  possible  to  eat  in 
ordinary  diet,  then  we  employ  albumoses  liberally,  and  generally  so 
mixed  with  the  food  (soups,  scraped  broiled  meats,  in  puree)  that 
the  patient  can  not  detect  them;  for  this  purpose  the  tasteless  and 
odorless  products — somatose,  Mosquera  beef-meal,  etc. — are  prefer- 
able. 

Rectal  Alimentation. — In  diseases  in  which  the  approach  to  the 
stomach  is  stenosed  (carcinoma  or  stenosis  of  the  esophagus  or 
cardia),  or  in  which  the  organ  requires  a  temporary  but  absolute 
exemption  from  work  (ulcer  and  some  forms  of  gastritis),  or  in  cases 
in  which  the  mildest  and  most  digestible  diet  is  not  tolerated,  it  be- 
comes necessary  to  support  the  strength  by  nutritive  rectal  enemata. 


RECTAL    AUMENTATION.  213 

The  history  of  the  evolution  of  the  nutritive  enema  is,  from  a 
physiological  standpoint;  very  interesting;  and  as  the  author  has 
at  various  times  done  considerable  experimental  work  in  this  line, 
a  brief  review  of  the  same  is  believed  essential  to  a  proper  under- 
standing of  the  subject. 

The  first  to  discover  that  the  human  colon  and  rectum  absorbed 
an  emulsion  of  eggs  and  w^ater  only  when  sodium  chlorid  was  added 
were  Voit  and  Bauer  ("Zeitschr.  f.  Biol.,"  1869,  Bd.  v).  They 
found  that  these  foods  were  not  absorbed  in  the  absence  of  salt, 
and  in  1871  Kichhorst  ("Phliiger's  Archiv,"  Jahrgang  iv,  71)  con- 
firmed their  results.  Injections  of  bouillon,  milk,  and  eggs  had  been 
used  long  before  this  time,  but  no  one  ever  attempted  to  ascertain 
to  what  degree  the  mucosa  of  the  large  intestine  would  absorb  it. 
In  1892  Leube  proposed  a  meat-pancreas  injection  ("Deutsch. 
Archiv  f.  khn.  Med.,"  Bd.  x,  Reihe  iii),  the  plan  emanating  from 
the  idea  to  transpose  something  of  the  character  of  pancreatic  diges- 
tion into  the  large  intestine.  The  preparation  of  this  useful  enema 
is  as  follows:  Take  150  to  300  gm.  of  very  finely  scraped  beef  and  50 
to  100  gm.  of  finely  chopped  pancreas  of  the  calf  or  pig,  and  mix  with 
the  addition  of  150  c.c.  luke-warm  water  in  a  bowl;  if  desired,  25  to 
50  gm.  of  fat  may  be  added  in  the  form  of  oil  or  butter;  the  injection 
must  be  made  at  the  body-temperature. 

We  have  convinced  ourselves  that  this  mixture  digests  thoroughly 
in  the  large  intestine;  its  preparation  is  complicated,  however,  re- 
quiring very  intimate  mixing,  and  it  rapidly  decomposes.  Teube 
reported  a  case  which  he  kept  alive  six  months  by  this  enema  ex- 
clusively, and  in  a  similar  way  Riegel  nourished  a  case  of  esophageal 
stricture  for  ten  months.  Ewald  demonstrated  that  egg-emulsion 
is  absorbed  without  being  peptonized  or  salted  ("Zeitschr.  f.  klin. 
Med.,"  Bd.  11),  and  Huber,  while  confirming  Ewald's  observation, 
added  that  the  addition  of  salt,  or  previous  peptonizing,  really 
doubled  the  amount  of  emulsified  eggs  that  was  absorbed  in  the 
colon.  Eggs,  it  must  not  be  overlooked,  contain  a  considerable 
amount  of  normal  salt,  and  this  may  explain  Huber's  results  ("Zeit- 
schr.  f.  klin.  Med.,"  Bd.  xlvii)  as  to  their  absorption  in  part,  even 
without  the  addition  of  salt.  But  it  is  an  established  fact  that  the 
addition  of  sodium  chlorid  very  much  increases  the  amount  of  eggs 
that  is  absorbed. 

In  a  very  interesting  series  of  experiments  Griitzner  ofi'ered  a 
physiological    explanation    of   this    phenomenon    ("Deutsche    med. 


214  DIETETIC   TREATMENT   OF    GASTRIC    DISEASES. 

Wochenschr.,"  1894,  No.  48),  having  demonstrated  that  under  cer- 
tain conditions  particles  of  charcoal,  finely  cut  horse-hair,  or  saw- 
dust, impregnated  with  normal  (0.6  per  cent.)  salt  solution  and  in- 
jected into  the  rectum  of  rabbits,  guinea-pigs,  and  rats,  are  found 
six  hours  later  all  along  the  small  intestine,  even  in  the  stomach, 
while  the  rectum  is  empty.  During  a  period  of  twenty-four  hours 
before  these  injections  the  animals  were  starved.  When  the  sus- 
pensions of  these  particles  were  made  in  distilled  water,  HCl  solution, 
or  potassium  chlorid  solution,  instead  of  physiological  salt  solution, 
the  particles  did  not  ascend  in  the  digestive  tract.  Griitzner  in- 
jected starch-suspensions  in  normal  NaCl  solution  into  the  rectum 
of  human  beings,  and  after  a  number  of  hours  demonstrated  starch- 
grains  in  the  gastric  contents,  microscopically.  Nothnagel  first 
showed  that  sodium  chlorid  placed  on  the  serous  surface  of  the  intes- 
tine is  capable  of  starting  antiperistaltic  movements  ("Beitrag  z. 
Ph5^siol.  u.  Pathol,  d.  Darms,"  1884),  and  Griitzner  interprets  this  ob- 
servation as  an  explanation  of  the  digestion  of  egg-enemata  containing 
salt.  He  assumes  that  the  injected  mass  is  moved  upward  through 
the  entire  small  intestine,  and  so  becomes  digested  and  absorbed. 
Even  Riegel  {loc.  cit.,  p.  245)  is  satisfied  with  this  interpretation, 
and  adds  that  it  explains  the  negative  results  of  Voit  and  Bauer 
without  salt,  and  the  positive  ones  with  salt,  and  also  those  of  Huber. 
In  our  opinion,  the  evidences  that  food-substances  move  anti- 
peristaltically  upward  in  the  intestine  are  not  satisfactorily  given  in 
Griitzner's  work.  It  is  undeniable  that  minute  particles  of  starch, 
charcoal,  etc.,  are  moved  from  the  rectum  toward  the  stomach  in 
man;  and  we  have  been  able  to  confirm  this  part  of  his  results,  as 
well  as  the  fact  that  salt  favors  the  ascent  and  HCl  and  KCl  im- 
pede it.  But  this  antiperistaltic  motion  we  conceive  to  be  only  a 
very  feeble  marginal  ascending  movement,  effected  by  surface  con- 
tact of  the  particles  with  the  epithelium,  which  in  turn  is  moved  by 
the  muscularis  mucosae.  This  very  slight  marginal  antiperistalsis 
is  never  visible  to  the  eye,  and  can  only  be  demonstrated  by  the 
progress  of  particles;  it  is  not  capable  of  propelling  food  masses;  on 
the  contrary,  we  have  convinced  ourselves  that  at  the  same  time  that 
the  marginal  peristalsis  drags  visible  particles  of  charcoal  toward  the 
stomach  with  infinitesimal  slowness,  there  may  be  an  uninterrupted 
current  of  central  food  masses  toward  the  anus.  The  marginal 
antiperistalsis  may  be  a  physiological  thing,  present  at  all  times,  and 
its  object  may  be  the  raising  or  drawing  up  of  portions  of  mucosa 


PATHOLOGICAL    ANTIPERISTALSIS.  215 

from  one  place  to  another  in  order  to  bring  new  surfaces  in  contact 
with  the  ingesta,  or  to  replace  a  portion  of  surface  to  its  normal 
topography  after  it  has  been  dragged  away  from  it  by  the  downward 
current.  The  cohesion  of  these  small  particles  with  the  mucosa  can 
be  seen  when  a  piece  of  fresh  animal  intestine  is  sprinkled  with 
lycopodium  or  finely  cut  horse-hair  particles  and  held  under  a  gentle 
stream  of  water;  the  gut  may  be  moved  upward  on  the  surface  of 
the  hand  while  the  water  moves  downward,  and  still  many  of  the 
particles  will  adhere. 

The  antiperistalsis  that  Nothnagel  produced  by  placing  crystals 
of  salt  upon  the  serosa  is  quite  a  different  thing,  for  it  is  plainly 
visible  to  the  eye,  and  never  occurs  under  physiological  conditions 
(Nothnagel,  "Erkrank.  d.  Darms,"  portion  on  "Die  Darmbewe- 
gung,"  p.  6,  1896).  Among  the  abnormal  conditions  that  may 
cause  this  visible  antiperistalsis,  Nothnagel  states  stronger  solutions 
of  sodium  chlorid  and  the  introduction  of  food  at  an  unphysiological 
entry,  as  which  in  man  we  must  consider  the  rectum.  He  adds  (loc. 
cit.)  that  from  a  physiological  entry,  i.  e.,  from  the  stomach,  the 
strongest  chemical  irritants  produce  only  peristaltic  movements 
toward  the  anus.  There  are,  then,  two  kinds  of  antiperistaltic  move- 
ments: (i)  Those  of  Griitzner,  being  marginal,  invisible,  possibly 
physiological,  and  not  capable  of  moving  food  masses;  (2)  those  of 
Nothnagel,  being  visible,  strong,  and  occurring  only  under  abnormal 
conditions.  Christomanos,  a  pupil  of  Nothnagel,  has  urged  an  objec- 
tion against  Griitzner's  results  that  seems  to  invalidate  the  conclu- 
sions of  the  latter;  namely,  he  found  (Christomanos,  "Z.  Frage  d. 
Antiperistaltik,"  "Wien.  klin.  Rundschau,"  1895,  Nos.  12  and  13) 
that  when  his  animals  were  prevented  from  licking  up  the  expelled 
rectal  contents  his  results  as  to  finding  the  particles  in  the  stomach 
were  negative.  Dauber  came  to  the  same  conclusion  as  Christo- 
manos, namely,  that  the  occurrence  of  particles  of  rectal  injections 
in  the  stomachs  of  animals  did  not  take  place  when  they  were  pre- 
vented from  eating  their  excrement.  These  objections  are,  how- 
ever, set  aside  by  Griitzner's  and  our  own  observations  on  the  human 
subject.  The  experiments  of  vSwiezynski  ("Deutsche  med.  Woch- 
enschr.,"  1895,  No.  32)  also  confirmed  Grutzner's  statements,  in  that 
lycopodium  injected  into  the  rectum  was  found  in  the  stomach. 

We  must,  however,  again  emphasize  that   this   antiperistalsis  is 
not  capable  of  moving  ingesta,  and  that  it  can  not  logically  be  taken 
as  an  explanation  of  the  digestion  of  enemata. 
'5 


2l6  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

The  fact  that  normal  salt  solution  favors  the  invisible  marginal 
ascent  of  particles,  and  that  other  chemicals  impede  it,  is  perfectly 
natural.  For  if  this  antiperistalsis  be  physiological,  and  be  assumed 
to  be  going  on  at  all  times,  normal  salt  solutions  can  not  disturb  it, 
for  they  are  the  physiological  environment  in  which  all  intestinal 
movements  occur.  But  HCl  and  KCl  are  chemical  irritants,  to  which 
the  muscularis  mucosae  reacts  by  efforts  at  expulsion. 

The  Occurrence  of  Proteolytic  Ferments  in  the  Colon  and 
Rectal  Contents. — The  author's  explanation  of  the  digestion  of 
egg  and  milk  emulsions  in  the  rectum  and  colon  is  quite  different 
from  Griitzner's  and  from  that  accepted  by  Riegel  and  others,  and 
is  based  on  a  very  carefully  conducted  series  of  experiments  on 
animals  and  human  beings.  We  desire  to  speak  only  of  actual  diges- 
tion, for  there  is  good  reason  for  believing  that  albumin,  fats,  etc., 
may  be  absorbed  from  the  large  intestine  as  such — without  digestion. 

Without  going  into  the  details  and  technic  of  these  experiments, 
we  will  briefly  state  the  conclusions.  After  the  rectal  contents  of 
dogs  or  cats  are  sterilized  with  saturated  solutions  of  thymol  (so 
strong  that  the  cr}^stals  float  on  top)  and  passed  through  a  Pasteur 
filter,  control  cultures  are  made  to  ascertain  that  the  watery  extract 
of  the  excrement  is  sterile.  For  this  purpose  the  meat  pepton- 
gelatin  and  agar  plates  recommended  by  Xothnagel  (loc.  cit.,  p.  22) 
are  most  convenient.  The  reaction  of  human  excrement  is  generally 
weaklv  alkaline  or  neutral;  very  rarely  weakly  acid  under  normal 
conditions.  This  watery  extract  of  normal  rectal  contents  contains 
a  substance  which  in  a  digestorium  (thermostat  at  40°  C),  and  in 
an  alkaline  medium  (equal  to  from  0.8  to  i  per  cent.  XajCOa),  dis- 
solves from  36.5  to  50  per  cent,  of  Merck's  dried  serum-albumin  in  three 
hours  under  aseptic  conditions.  It  will  also  digest  fibrin,  and  has. 
in  addition,  a  faint  amylolytic  power,  converting  from  10  to  14.5 
per  cent,  of  starch  into  maltose  in  an  alkaline  medium  of  0.3  per 
cent.  XajCOj.  We  have  not  been  able  to  find  any  fat-splitting  action 
in  this  extract. 

As  there  are  many  bacteria  that  produce  peptone  in  the  breaking 
down  of  proteid,  and  others  that  ferment  carbohydrates,  the  previous 
sterilization  is  necessary-  in  order  to  exclude  their  action.  Bacteria 
do  not  make  peptone  for  any  philanthropic  purposes;  the  peptone 
they  give  rise  to  is  an  intermediate  stage  in  a  long  series  of  decom- 
position products.  It  does  not  remain  peptone,  but  is  rapidly  de- 
composed into  amido-acids,  ammonia,   tyrosin,  etc.,  and  does  not 


RECTAL    COXTEXTS    AFTER    STERILIZATIOX.  217 

occur  in  the  intestine  as  peptone  pure  and  simple,  but  mixed  with  a 
number  of  other  derivatives  of  albumen,  some  of  which  are  proven 
to  be  toxic.  We  state  this  because  even  among  medical  men  the 
opinion  has  been  encountered  that  the  bacterial  peptone  might  be 
of  utility  to  the  organism  in  which  it  is  formed.  The  feces  for  our 
purposes  can  not  be  sterilized  by  heat,  because  that  would  destroy 
any  possible  enzymes  present. 

It  is  certain,  therefore,  that  rectal  contents  contain  a  proteolytic 
ferment ;  also  one  having  a  slight  amylolytic  power,  acting  only  in  a 
faintly  alkaline  medium,  the  action  being  destroyed  in  an  acid 
medium.  \\'hether  these  two  digestive  actions  are  carried  out  by 
one  and  the  same  ferment  or  by  two  different  ferments  we  are  unable 
to  say.  That  it  can  not  be  pepsin  is  proven  by  the  fact  that  it  does 
not  act  in  an  acid,  but  only  in  an  alkaline,  medium. 

It  would  be  interesting  to  learn  whether  the  walls  of  the  large 
intestine  secrete  any  proteolytic  ferment.  The  colon  of  a  dog  that 
is  kept  clear  of  fecal  masses  by  making  an  abdominal  fistula  and 
sewing  it  to  the  abdominal  wall  at  the  ileocecal  valve,  secretes  an 
alkaline  fluid,  which  has  no  proteolytic  powers  whatever,  but  there 
is  an  evident  amylolytic  ferment  contained  in  it.  The  human  colon 
can  be  plugged  up  in  the  transverse  portion  by  introducing  a  balloon 
and  blowing  it  up;  thereafter  the  part  between  the  rubber  balloon 
and  the  anus  is  washed  out  with  sterile  normal  salt  solution.  A 
secretion  is  formed  in  two  to  three  hours,  and  can  be  collected  on 
absorbent  cotton  placed  in  the  rectum,  and  later  squeezed  out  into  a 
small  beaker.  The  secretion  is  alkaline,  but  has,  after  filtration 
through  a  Pasteur  filter,  no  proteolytic  power.  Therefore,  it  is 
reasonable  to  assume  that  the  ferment  we  have  demonstrated  is 
derived  from  the  pancreas.  In  two  patients  with  total  atrophy  of 
the  gastric  mucosa  (atrophic  gastritis),  as  evidenced  by  fragments 
of  the  mucosa  found  in  the  wash-water,  the  same  proteolytic  ferment 
was  demonstrable  in  the  colon  contents.  It  was  hitherto  assumed 
that  the  ferments  of  the  pancreas  were  destroyed  in  the  intestine 
(see  Rosenheim,  "Die  Erkrank.  d.  Darms,"  p.  46).  A  large  number 
of  similar  experiments  as  above  described  justifies  the  belief,  how- 
ever, that  trypsin  and  perhaps  amylopsin  may  survive  the  passage 
through  the  bowel.  Busch  has  shown  that  digestion  may  go  on  in 
the  human  intestine  without  gastric  or  pancreatic  juice,  without  bile 
and  secretion  of  Brunner's  glands  (Briicke's  " \'orlesungen  iiber 
Physiologie,"  Wien,    1885,   p.   352).     The  patient  on  whom   Busch 


2l8  DIETETIC   TREATMENT    OF    GASTRIC    DISEASES 

experimented  had  received  an  abdominal  injury  by  an  accident,  in 
such  a  manner  that  the  gastric  juice,  together  with  the  chyme,  pan- 
creatic juice,  duodenal  secretions,  and  bile,  ran  outward  through  a 
fistula.  Thereafter,  Busch  fed  him  through  the  fistulous  opening 
communicating  with  the  lower  bowel,  and  succeeded  in  maintaining 
the  nitrogenous  equilibrium.  He  lowered  coagulated  albumin  in- 
closed in  small  cotton  bags  into  the  bowel,  and  drew  them  out  by 
a  string  five  hours  later,  finding  that  from  five  to  thirty-five  per 
cent,  of  the  albumin  was  dissolved.  In  Busch's  experiments  the 
action  of  the  bacteria  can  not  be  excluded.  The  action  of  the  succus 
entericus  may  explain  the  carbohydrate  digestion,  but,  as  no  proteo- 
lytic ferment  could  enter  the  small  intestine,  the  digestion  of  albumin 
was  probably  due  to  bacteria. 

In  conclusion  we  may  say  that  rectal  enemata  are  digested  prob- 
ably by  pancreatic  ferments  passing  through  the  bowel,  by  bacteria, 
and  by  the  succus  entericus,  which,  even  in  the  colon,  has  an  amylo- 
l)rtic  action;  that  certain  foods — egg-albumen,  fats,  milk — can  be 
absorbed  as  such  without  being  digested.  Griitzner's  marginal 
ascending  motion  of  particles  can  not  move  ingesta  upward.  F. 
Mall  ("Johns  Hopkins  Hospital  Reports,"  vol.  i,  p.  70)  holds  that 
the  propelling  force  of  the  intestines  normally  acts  in  one  direction 
only ;  the  antiperistalsis  is  found  only  as  a  pathological  phenomenon, 
and  all  of  his  efforts  to  force  the  intestine  to  work  in  the  wrong 
direction  by  reversal  {loc.  cit.,  p.  93)  were  negative.  Under  condi- 
tions of  great  irritation  rectal  contents  may  be  vomited. 

Preparation  of  Rectal  Enemata : 

Indications  and  Methods  of  Administration. — The  preparation  of 
Ewald's,  Leube's,  and  Boas'  nutritive  enemata  is  given  under  the 
dietetic  tables.  Jaccoud  recommends  250  gm.  of  bouillon,  120  gm. 
of  wine,  yolks  of  two  eggs,  5  to  20  gm.  of  peptone.  Rosenheim  uses 
peptone  (one  to  two  drams),  two  eggs,  15  gm.  of  glucose,  and  some- 
times, if  desired,  emulsions  of  cod-liver  oil.  Singer's  enema  ("Cen- 
tralblatt  d.  ges.  Therap.,"  Marz,  1895)  is  very  much  like  that  of 
Boas,  with  the  addition  of  peptone.  These  examples  will  amply 
suffice  for  all  purposes. 

Method  and  technics  of  rectal  feeding: 

(i)  Every  nutritive  injection  must  be  preceded  by  a  cleansing  in- 
jection one  hour  previously. 

(2)  The  amount  of  injected  nutriment  must  not  exceed  ^  of  a 
liter  (Sviij)  at  a  time. 


PREPARATION   OF    NUTRITIVE   ENEMATA.  219 

(3)  After  the  injection  the  patient  must  remain  in  the  recumbent 
position  for  one  hour,  and  a  hot  towel  should  be  held  firmly  against 
the  anus  for  fifteen  or  twenty  minutes. 

(4)  The  patient  should  lie  on  his  left  side  with  his  hips  raised  upon 
a  pillow,  and  the  injection  must  be  given  very  gradually. 

(5)  If  the  rectum  is  very  irritable,  the  addition  of  a  few  drops  (10 
to  20)  of  tincture  of  opium  is  serviceable. 

(6)  The  injection  should  be  made  with  a  funnel  or  an  irrigating 
bottle,  never  with  a  syringe.  The  best  tube  to  use  is  that  named 
after  Langdon,  as  it  is  sufficiently  soft  and  flexible  and  can  not  kink 
upon  itself. 

(7)  The  tube  should,  in  adults,  be  passed  high  up  into  the  colon; 
if  possible,  14  to  18  inches  should  be  introduced,  but  12  inches  will, 
as  a  rule,  suffice.  The  higher  up  the  enema  is  placed,  the  less  will 
be  the  liability  of  its  rejection.  An  anatomical  and  physiological 
reason  for  placing  injections  high  is  found  in  the  nature  of  the  anasto- 
moses of  the  vascular  supply  of  the  rectum,  sigmoid,  and  colon.  The 
superior  rectal  and  sigmoid  veins  communicate  with  the  inferior 
mesenteric  vein,  therefore  these  veins  conduct  whatever  they  have 
absorbed  directly  to  the  liver  through  branches  of  the  vena  porta. 
In  the  liver  the  very  important  secondary  digestion  takes  place. 
The  veins  from  the  lower  third  of  the  rectum  communicate  with  the 
inferior  vena  cava,  and  their  contents  are  not  conducted  to  the, 
liver. 

(8)  The  temperature  of  the  injection  should  be  that  of  the  body — 

98.6°  R 

Indications  Necessitating  Rectal  Feeding.— There  are  two 
classes  of  conditions  in  which  nutritive  enemata  are  indicated : 

I.  The  first  class  comprises  patients  that  are  still  able  to  swallow 
food  and  willing  to  do  so,  but  on  account  of  the  existence  of  some 
gastric,  esophageal,  or  duodenal  disease  it  is  necessary  or  expedient 
to  rest  the  stomach  and  exempt  it  from  work.     These  are : 

(i)  Gastric  Ulcer.— For  the  purpose  of  keeping  the  ulcer  free  from 
irritation  and  permitting  it  to  heal  or  to  prevent  the  starting  up  of 
hematemesis. 

(2)  Dilatations.— Either  in  the  atonic  or  benign  forms,  to  attempt 
a  cure  by  relieving  the  stomach  of  the  weight  of  ingesta  and  the 
constant  fermentation;  or  in  the  malignant,  pyloric,  and  stenotic 
forms,  because  food  positively  can  not  pass  the  pylorus  and  gastro- 
enterostomy is  refused  or  impossible. 


220  DIETETIC    TREATMENT   OV    GASTRIC    DISEASES. 

(3)  Severe  gastric  irritations,  as  in  toxic  gastritis. 

(4)  Exhausting  diseases,  especially  the  infectious  types,  where 
secretion  and  absorption  are  inhibited  and  food  not  retained,  though 
swallowed. 

(5)  Ulcer  of  the  esophagus  or  duodenum,  stricture,  ileus,  invag- 
ination, volvulus,  stenosis  of  any  part  of  the  alimentary  tract  between 
stomach  and  rectum. 

II.  The  conditions  in  which  the  patients  are  unable  to  swallow 
food  are: 

(i)  Temporary  obstruction  to  the  entrance  of  food  into  the  ali- 
mentary canal;  presence  of  new  growths;  foreign  bodies;  acute 
inflammations  about  mouth,  pharynx,  and  esophagus. 

(2)  Extreme  sensitiveness  of  the  mouth  and  esophagus  excited  by 
corrosive  poisons. 

(3)  Carcinoma,  cicatricial  contraction,  diverticulum,  neoplasms,  of 
esophagus ;  carcinoma  of  cardia. 

(4)  Reflex  vomiting,  as  in  pregnane}^  and  sea-sickness. 

There  are  other  states  in  which  the  patients  are  either  unable  or 
unwilling  to  swallow  food,  but  in  these  feeding  by  the  tube  is  prefer- 
able to  rectal  feeding.  These  are:  (a)  Inability  to  swallow  from 
coma,  delirium,  or  paralysis  of  the  muscles  of  deglutition;  post- 
diphtheritic paralysis.  (6)  Insanity,  refusal  of  food,  (c)  Total 
^anorexia  (hysterical,  etc.). 

Intravascular  and  Hypodermic  Feeding. — In  1850  Hodder  first 
practised  intravenous  injection  of  milk  in  cases  of  collapse  from  chol- 
era Asiatica.  T.  G.  Thomas  about  this  time  published  a  case  in 
which  ^  of  a  pint  of  milk  warmed  to  body-temperature  was  injected 
into  one  of  the  brachial  veins,  with  the  result  of  saving  life.  Accord- 
ing to  Oilman  Thompson  {loc.  cit.,  p.  383),  Fowler  has  practised 
intravenous  injection  of  peptone  and  has  also  given  six  ounces  of 
digested  beef  solution  in  this  manner.  There  seems  to  us  no  physio- 
logical reason  why  intravenous  or  even  intra-arterial  feeding  should 
not  be  practised  in  emergencies.  As  a  safeguard,  however,  we  would 
suggest  that  every  precaution  be  taken  to  have  the  injection  abso- 
lutely sterile,  and  composed  of  such  substances  as  are  normal  to  the 
blood,  such  as  serum-albumin,  sterile  plasma,  defibrinated  fresh 
sterile  blood.  Much  careful  experimenting  is  required,  however, 
before  we  can  be  justified  in  using  such  methods  on  the  sick  human 
being.  Intravenous  and  intra-arterial  injections  of  warm,  sterile, 
normal  salt  solutions  have  been  extensivelv  used  in  Asiatic  cholera 


SUBCUTANEOUS    FEUDING.  221 

and  in  exhausting  hemorrhages.  We  have  had  occasion  to  use  them 
in  hematemesis  after  gastric  ulcer,  with  the  conviction  that  hfe  was 
saved  thereby.  Transfusion  of  sterile,  normal  salt  solution  mto  the 
areolar  connective  tissue  of  the  breast  is  to  be  preferred  to  these 
methods,  because  it  requires  only  a  pressure-bottle  and  sterile,  sharp- 
pointed  cannula— no  other  instruments. 

Subcutaneotis  Feedtnq. -In  1869  Menzel  and  Perco  injected  fats, 
albumin,  and  sugar  into  dogs  and  human  beings,  and  showed  that 
liquid  oils  were  resorbed  without  causing  local  or  general  reaction. 
They  injected  nine  gm.  of  oil  into  one  patient,  at  Billroth's  clmic, 
who  had  spinal  caries;  a  swelling  as  large  as  a  silver  dollar  ensued, 
but  disappeared  entirely  in  thirty  hours  ("Wiener  med.  Woch- 
enschr.,"  1869,  No.  31).  _      . 

Attempts  have  been  made  in  the  human  being  with  injection  ot 
defibrinated    calf's-blood    by    Landenberger    ("Wiirtemberg.    med. 
Correspondenzbl.,"  Bd.  xliv,  No.  20),  with  olive  oil  by  Krueg  (Re- 
ferat  in  "Wien.  med.  Wochenschr.,"   1875,  No.  34),  with  olive  oil 
and  milk  by  Whittaker  ("Schmidt's  Jahrb.,"  Bd.  CLXXVii,  Heft  i), 
who  in  eight  sittings  injected  124  gm.  in  one  day-in  all  he  made 
68   injections.     Karst   recommended    defibrinated   blood    ("Berlin, 
klin.  Wochenschr.,"   1873,  No.  49)-     Kichhorn  was  so  enthusiastic 
with  his  injections  of  milk-peptone  and  cod-liver  oil  that  he  believed 
the  normal  nutrition  of  an  animal  could  be  supplanted  by  this  method 
("Wien.  med.  Wochenschr.,"   1881,  Nos.   32,   33,  and  34)-     Teube 
proved  that  oils  injected  subcutaneously  were  actually  used  up  m 
the  metabolism  of  the  body  (Leube,  " Verhandlung.  d.  XIV.  Con- 
gresses f.  innere  Medicin,"  1895)-     In  a  case  of  benign  hyperplastic 
pyloric  stenosis  complicated  by  colitis,  the  author  and  his  associate. 
Dr.  Harry  Adler,  injected  24  gm.  of  sterilized  olive  oil  under  the  skm 
daily  for  three  weeks.     Nutritive  enemata  were  not  tolerated  on 
account  of  the  colitis.     The  oil  injections,  which  did  not  cause  the 
slightest  irritation,  were  absorbed  in  from  four  to  twelve  hours,  and, 
though  no.  analyses  on  metabolism   could  be  executed,  it  became 
evident  that  the  patient  was  benefited  by  the  hypodermic  use  of  oil. 
In  spite  of  these   experiments,    it   is   very  doubtful   whether   sub- 
cutaneous injections  of  nutritive  materials   can  ever  be  utilized  to 
supplant  normal  feeding.     The  caloric  value  of  the  amounts  that 
are  available  for  injection  is  comparatively  insignificant,  the  method 
quite  irritating,  and  in  progressed  sufferers  hardly  justifiable. 


APPROXIMATE   ANAlvYSES   OF   A   MAN. 


TABLES  OF  DIETETICS. 

APPROXIMATE  ANALYSES  OF  A  MA'N.—{Moss. 
(Height,  5  feet  8  inches;  weight,  148  pounds.) 
Pounds, 


Oxygen, 92.4 

Hydrogen, 14. 6 

Carbon, 31.6 

Nitrogen, 4.6 

Phosphorus, 1.4 

Calcium, 2.8 

Sulphur, 0.24 

Chlorin, 0.12 


Pounds. 

Sodium, 0.12 

Iron, 0.02 

Potassium, 0.34 

Magnesium, 0.04 

Silica, ? 

Fluorin, 0.02 


Total, 148.30 


Landois  and  Stirling  give  the  following  table,  which  differs  some- 
what from  the  other  tables  in  the  relative  proportion  of  fats  and 
starches.  An  adult  doing  a  moderate  amount  of  work  takes  in  as 
food  per  diem: 


C. 

H. 

N. 

0. 

120  gm.  of  albumin,  containing,  .... 

90  gm.  of  fats,  containing, 

330  gm.  of  starches,  containing,    .... 

64.18 
70.20 

146.82 

8.60 
10.26 
20.33 

18.88 
.     .     . 

28.34 

9-54 

162.85 

281.20 

39-19 

18.88 

200.73 

Add      744. 1 1  gm.  of  O  from  the  air  by  respiration. 
"    2,8i8.co    "    of  Ufi. 
"         32.00    "    of  inorganic  compounds  (salts). 


The  whole  is  equal  to  three  kilogm.  and  a  half  (seven  pounds), 
i.  e.,  about  one-twentieth  of  the  body- weight;  so  that  about  six  per 
cent,  of  the  water,  about  six  per  cent,  of  the  fat,  about  one  per  cent, 
of  the  albumin,  and  about  0.4  per  cent,  of  the  salts  of  the  body  are 
daily  transformed  within  the  organism. 

An  adult  doing  a  moderate  amount  of  work  gives  off  in  gm. : 


By  respiration,  . 
By  perspiration. 
By  urine,  .  .  . 
By  feces,     .    .    , 


Water. 

C. 

H. 

N. 

330 
660 

248.8 
2.6 

? 

1,700 

9.8 

3-3 

15.8 

128 

20.0 

30 

3-0 

2,818 

281.2 

6.3 

18.8 

65II5 

7.2 

II. I 

12.0 

681.45 


STANDARDS   FOR   DAILY   DIETARIES. 


223 


STANDARDS  FOR  DAILY  DlKTKRl'ES.  — [Compiled  by  Atwater.) 
Weights  of  nutrients  and  calories  of  energy  (heat-units)  in  nutri- 
ents required  in  food  per  day : 


Nutrients. 

Potential 

Energy. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

Gm. 

Gm. 

Gm. 

Gm. 

Calories. 

Children  to  a  year  and  a  half,  . 

28 

Zl 

75 

140 

767 

(20-36) 

(30-45) 

(60-90) 

Children  of  two  to  six  years,    . 

55 

40 

40 

295 

1,418 

(36-70) 

(35-48) 

(100-250) 

Children  of  six  to  fifteen  years, 

75 

43 

325 

443 

2,041 

(70-80) 

(37-50) 

(250-400) 

Aged  women, 

80 

50 

260 

390 

1,859 

Aged  men, 

100 

68 

350 

518 

2,477 

Woman  at  moderate  work,  Voit, 

92 

44 

400 

536 

2,426 

Man  at  moderate  work,    Voit,  . 

118 

56 

500 

674 

3>o55 

Man  at  hard  work,   Voit,  .    .    . 

145 

100 

450 

695 

3,370 

Man     at     moderate    exercise, 

Flay  fair, 

119 

51 

531 

701 

3,139 

Active  labor,  Play/air,     .    .    . 

156 

71 

568 

795 

3,629 

Hard  labor.  Play  fair, 

185 

71 

568 

824 

3,748 

Woman  with  light  exercise,  At- 

■water, 

80 

80 

300 

460 

2,300 

Man   with    light    exercise,    At- 

jvater,       .    .         

100 

100 

360 

460 

2,820 

Man  at  moderate  work,  Atwater, 

125 

125 

450 

700 

3,520 

Man  at  hard  work,  Atwater, 

150 

150 

500 

800 

4,060 

Man  at  moderate  work,  Mole- 

schott,       

130 
120 

40 

550 
540 

720 

3,160 
3,032 

Man  at  moderate  work,  Wolff, 

35 

695 

Table  of  analyses  made  by  Dujardin-Beaumetz,  showing  the  pro- 
portion of  nitrogen  present  and  also  the  combustibles  calculated  as 
carbon : 


Beef,  uncooked,  , 
Roast  beef,  .  .  . 
Calf's-liver,  .  . 
Foie  gras,  .  .  . 
Sheep's  kidneys. 
Skate,  .  .  .  . 
Cod,  salted,  . 
Herring,  salted,  . 
Herring,  fresh,  . 
Whiting,  .  .  .  , 
Mackerel,      .    .    . 


C  -f  H 

Nitrogen. 

Combustibles 

Calculated  as 

Carbon. 

3.00 

11.00 

3-53 

17.76 

309 

15.68 

2.12 

65.58 

2.66 

12.13 

3-83 

12.25 

5.02 

16.00 

3" 

23.00 

1.83 

21.00 

2.41 

9.00 

3-74 

19.26 

224 


STANDARDS    FOR    DAII^Y   DIETARIES. 


Table  of  analyses  showing  the  proportion  of  nitrogen  and  combustibles  calculated 
as  carbon  i^Continued). 


Sole,      ... 

Salmon, .    .    .    . 

Carp, 

Oysters, 

Loljster,  uncooked, 

Eggs, 

Milk,  cow's, 

Cheese  (Brie),      

Cheese  (Gruyere), 

Cheese  (Roquefort), 

Chocolate, 

Wheat  (hard  southern,  variable  average),  . 
Wheat  (soft  southern,  variable  average),     . 

Flour,  white  (Paris), 

Rye  flour, 

Winter  barley,  

Maize,       

Buckwheat, 

Rice,  

Oatmeal , •    •    .    .    . 

Bread,  white  (Paris,  30  per  cent,  water),  . 
Bread,  brown  (soldiers'  rations  formerly),  . 
Bread,  brown  (soldiers'  rations  at  present). 

Bread  from  flour  of  hard  wheat, 

Potatoes, 

Beans, 

Haricots,  dry, .    . 

Lentils,  dry, 

Peas,  dry 

Carrots, • 

Mushrooms, .    .    . 

Figs,  fresh, 

Figs,  dry,     

Plums, 

Coffee  (infusion  of  loogm.), 

Tea  (infusion  of  loo  gm.), 

Bacon,  

Butter,  fresh, 

Olive    oil, 

Beer,  strong,    . 

Wine, 


C+  H 

Combustibles 

Calculatkd  as 

Carbon. 

1. 91 

12.25 

2.09 

16.CO 

3-49 

12.10 

2.13 

7.18 

2.93 

10.96 

1.90 

13-50 

0.66 

8.00 

2.93 

35.00 

5.00 

38.00 

4.21 

44-44 

1-52 

58.00 

3.00 

41.00 

1.81 

39.00 

1.64 

38.50 

1-75 

41.00 

1.90 

40.  CO 

1.70 

44.00 

2.20 

42.50 

1.80 

41.00 

1-95 

44.00 

1.08 

29.50 

1.07 

28.00 

1.20 

30.00 

2.20 

31.00 

0.33 

11.00 

4-50 

42.00 

392 

43.00 

3-87 

43.00 

3.66 

44.00 

0.31 

5-50 

0.60 

4.52 

0.41 

15-50 

0.92 

34.00 

0.75 

28.00 

1. 10 

9.00 

I. CO 

10.50 

1.29 

71.14 

0.64 

83.00 

98.00 

0.05 

4-50 

0.15 

4.00 

THE    RELATIVE    VALUE    OF   FOODS'. 


225 


THE    RELATIVE  VALUE    OF    FOODS.  — {Scamme//.) 
(The  figures  represent  percentages.) 


Wheat,  .  .  . 
Barley,  .  .  . 
Oats,  .... 
Northern  corn. 
Southern  corn, 
Buckwheat, 
Rye,  .... 
Beans,  .... 

Peas 

Lentils,     .    .    . 
Rice,     .... 
Potatoes,  .    .    . 
Sweet  Potatoes, 
Parsnips,  .    .    . 
Turnips,    .    .    . 
Carrots,     .    .    . 
Cabbage,      .    . 
Cauliflower, 
Cucumbers, 
Milk  of  cow,    . 
Milk,  human,  . 
Veal,     .... 

Beef 

Lamb,  .... 
Mutton,    .    .    . 
Pork,    .... 
Chicken, 
Codfish,    .    . 
Trout,  .... 
\  Smelt,  .... 
Salmon,    .    .    . 
Eels,     .... 
Herring,  .    .    . 
Halibut,   .    . 
Oysters,    .    . 
Clam,   .... 
Lobster,   .    .    . 
Eggs,  white  of, 
Eggs,  yolk  of. 
Butter,      .    .    . 
Artichoke,    .    . 
Asparagus,  .    . 
Bacon,      .    ,    . 
Carp,    .... 
Cheese,     .    .    . 
Cherries, 
Chocolate,    .    . 
Cream,      .    .    . 
Currants,       .    . 
Dates,  fresh,    . 
Figs,     .    .    . 
Ham,    .... 
Horse-radish,  . 
Kidney,    .    .    . 
Lard,    .... 


As  Mate- 
rial FOR 

THE 

Muscles. 


14.6 
12.8 
17.0 
12.3 
34-6 
8.6 

6.5 
24.0 

23-4 
26.0 

51 

1.4 

1-5 

2.1 

1.2 

I.I 

1.2 

3-6 

0.1 

50 

3-0 

17.7 

19.0 

19.6 

21.0 

17-5 

2[.6 

16.5 
16.9 
17.0 
20.0 
17.0 
18.0 
18.0 
12.6 
12.0 
14.0 
13.0 


1.9 
0.6 

8.4 

18.0 

30.8 

0.6 

8.8 

3-5 
0.9 


5-0 
35-0 

0.1 
21.2 


As  Heat 
Givers. 


66.4 
52.1 
50.8 

67-5 
39-2 
530 
75-2 
40.0 
41.0 

390 
82.0 

15-8 
21.8 

14.5 

4.0 
12.2 

6.2 

4.6 

1-7 
8.0 
7.0 

14-3 
14.0 

14-3 

14.0 

16.0 

1.9 

i.o 

0.8 

very  little 

some  fat 


very  little 


29.8 

100.  o 

19.0 

5-4 

62.5 

0.8 

28.0 

21.0 

88.0 

4-5 
6.8 

73-7 

57-9 

32.0 

4.8 

0.9 

lOO.O 


As  Food 

FOR    THE 

Brain  and 
Nervous 
System. 


1.6 
4.2 

3-0 
I.I 
4.1 
1.8 
05 
3-S 
2.5 
1-5 
0-5 
0.9 
2.9 
1.0 

0-5 
1.0 
0.8 
1.0 

0-5 
1.0 

05 

2-3 

2.0 

2.2 
2.0 
2.2 
2.8 

2-5 

4-3 

5  or  6 

6  or  7 

3  or  4 

4  or  5 
3  or  4 

0.2 
2  or  ^ 

5  or  6 
2.8 
2.0 

"  1.8 

0.4 

0-5 
2.9 

4-7 
1.0 
1.8 

0.3 

3-4 
4-4 
1.0 
1.4 


Water. 


14.0 
14.0 
13.6 
14.0 
14.0 
14.2 

13-5 
14.8 
14.1 
14.0 
9.0 
74.8 
67-S 
79-4 
90.4 
82.5 

91-3 
90.0 
97.1 
86.0 
89-5 
65-7 
65.0 

63-9 
63.0 

64-3 
73-7 
80.0 
78.0 

75-0 
74.0 

75-0 

75-0 
74.0 
87.2 

79-9 
84.2 

51-3 

76.6 
93-6 
28. 6 

78.3 
36-5 
76.3 

92.0 
81.3 
24.0 
18.7 
28.6 
78.2 
76.5 


Waste. 


3-4 
16 
16 

5 


10. 

2. 

15- 

"16. 


2  26  PERCENTAGES   OF   NUTRITION,    ETC. 

THE    RELATIVE   VALUE    OF    FOODS   {ConHiiued). 


Articles. 


Liver,   .    .  . 

Onions,     .  . 
Pearl  barley, 

Pears,  .    .  . 

Pigeon,     .  . 

Prunes,     .  . 
Radishes, 

Suet,     .    .  . 

Venison,  .  . 

Vermicelli,  . 

Whey,      .  . 


As  Mate- 
rial FOR 

THE 

Muscles. 


26.3 

4-7 

0.1 

23.0 

3-9 
1.2 


20.4 

47-5 


As  Heat 
Givers. 


3-9 

5-2 

78.0 

9.6 

1-9 

78.6 

7-4 

100. o 

8.0 

38.0 

4.6 


As  Food 
for  the 
Brain  AND 
Nervous 
System. 


1.2 

o.S 
0.2 

2.7 

4-5 
i.o 

2.8 

1-7 
0.7 


Water. 


68.6 
93-8 

9-5 
86.4 
72.4 
13.0 
89.1 

68.8 
12.8 
94-7 


Waste. 


7.6 
3-9 


1-3 


ATKINSON'S   TABLE    OF    DIGESTIBILITY   OF    NUTRIENTS    OF    FOOD 

MATERIALS. 


In  the  Food  Materials  Below. 


Of  the  Total  Amounts  of  Protein,  Fats,  and  Carbo- 
hydrates, THE  Following  Percentages 
were  Digested  : 


Meat  and  fish,   .    . 

Eggs,      

Milk,      

Butter, 

Oleomargarine, 
Wheat  bread,     .    . 
Corn  (maize)  meal, 

Rice, 

Peas, 

Potatoes,    .... 
Beets,     .... 


Protein. 


Practically  all 


to  100 


81  to  100 


84 
86 

74 
72 


Fats 


79  to  92 

96 
93  to  98 

98 


Carbohydrates. 


99 
97 
99 
96 
92 
82 


PERCENTAGES   OF   NUTRITION   IN   VARIOUS   ARTICLES    OF   FOOD. 


{Moss.) 


Raw  cucumbers, .     2 

Raw  melons, 3 

Boiled  turnips, 4^ 

Milk, 7 

Cabbage, J]4. 

Currants 10 

Whipped  eggs, 13 

Beets, 14 

Apples,     ....        , 16 

Peaches, 20 

Boiled  codfish,  21 

Broiled  venison, 22 

Potatoes, 22^ 

Fried  veal, 24 

Roast  poultry, 26 


Raw  beef, 26 

Raw  grapes, -27 

Raw  prunes, 29 

Boiled  mutton 30 

Oatmeal  porridge, 75 

Rye  bread, 79 

Boiled  beans, 87 

Boiled  rice, 88 

Barley  bread, 88 

Wheat  bread, 90 

Baked  corn  bread, 91 

Boiled  barley, 92 

Butter, 93 

Boiled  peas, 93 

Raw  oil, 96 


REQUISITE  EOOD  PERCENTAGES  IN  HEALTH.         227 

The  average  percentage  of  the  different  food  classes  needed  to 
sustain  a  man  in  perfect  health  is  given  in  Kensington  Miiseum 
"Handbook  on  Food": 

Per  Cent. 

Water, 81.5 

Albuminoid.s  or  flesh-formers, 3.9 

Starches  and  sugars, 10. 6 

Fat, 3.0 

Salt(NaCl), 0.7 

Phosphates,  potash  salts,  etc. , 0.3 


AN  IDEAL  RATION  WITH  SOLID  FOOD.  — {Mrs.  E.  H.  Richards. 


Material. 

Amount. 

Proteid. 

Fat. 

Carbo- 
hydrates. 

Gm. 

Ozs. 

Gm. 

Ozs. 

Gm. 

Ozs. 

Gm. 

Ozs. 

Bread,  .... 
Meat 

453-6 

226.8 

226.8 

28.3 

113-4 

453-6 

28.3 

14.17 

16 
8 
8 
I 

4 

16 

I 

31-75 

34.02 

12.52 

6.60 

3-63 
18.14 

1. 12 
1.20 

0.44 
0.23 
0.13 
0.64 

2.26 

11-34 
2.04 

7-50 

4.42 

18.14 

0.08 
0.04 
0.07 
0.26 
0.16 
0.64 

257.28 

9.04 

1,206.82 

243.72 

70.01 

135-42 

75-55 
613.21 
112. 17 
118.62 

Oysters,    .    .    . 
Breakfast  cocoa. 
Milk,    .... 
Broth,  .... 
Sugar,  .... 
Butter,      .    .    . 

9.60 

4.88 

90.72 

27.36 

0.34 
0.17 
3.20 
0.96 

0.14 

12.27 

Total,  .    . 

106.80 

57-97 

389.84 

2,575-52 

The  following  table  is  a  fair  average  work  ration  in  round  numbers, 
based  on  such  data  as  those  in  the  other  tables : 

ESTIMATED  WORK   RATION,  MAXIMUM  AND  MINIMUM.— 
{Mrs.  E.  H.  Richards.) 

For  One  Day. 

Proteid,  gm., \  ^ 

'  *>      '  \      IIO 

Fat,gm., \      ^^5 

'8      '  I       90 

Carbohydrates,  gm., \      ^^ 

Calories, <  ■''-' 

\  3,000 

About  30  gm.  of  salts  should  be  added  to  this  (Landois).     The  bare 
subsistence  ration  is  much  less,  as  follows : 


ESTIMATED  LIFE  RATION.— (J/;-:r.  E.  H.  Richards.) 


Proteid,  gm. 
Fat,  gm. ,     . 


For  One  Day. 

-    •        75 
.    .        40 


For  One  Day. 
Carbohydrates,  gm.,  .    .    .      325 
Calories, 2,000 


228 


ENERGY   PRODUCED    BY   FOODS. 


It  will  be  observed  that  the  totals  are  somewhat  less  in  this  diet 
than  those  of  the  preceding  table,  which  is  designed  for  a  working 
man  who  is  developing  more  calories. 

TABLE  OF   ENERGY. 
Estimated  in  Foot-tons  instead  of  Calories. — (  Veo.) 

Energy  developed  by  one  ounce  of  the  following  foods  when 
oxidized  in  the  body: 


Food  Stuff. 


Beef  (best  quality),  uncooked,  .  .  . 
Meat  (served  to  soldiers),  uncooked, 
Beef  (fattened],  uncooked,    .... 

Meat,  cooked,  

Corned  beef  (Chicago),  ...... 

Salt  beef,       

Salt  pork, 

Fat  pork, 

Dried  bacon, 

Smoked  ham, 

Whitefish,         

Poultry, 

Bread, 

Wheat-flour, 

Biscuit, 

Rice, 

Oatmeal,    .         . 

Maize, 

Macaroni, 

Millet, 

Arrowroot, 

Peas  (dried), 

Potatoes, .    . 

Carrots, 

Cabbage,  

Butter 

Eggs, 

Cheese, 

Milk  (cows'),  new, 

Cream,  

Skimmed  milk, 

Sugar, 

Pemmican, . 

Ale  (Bass's  bottled) 

Stout  (Guinness), 


with  usual 

Percentages  of 

Water. 

One  Ounce 
Water  Free. 

Foot-tons. 

Foot-tons. 

48.5 

199 

57.« 

243 

96.0 

280 

102.6 

240 

124.0 

.217 

52.0 

138 

71.6 

166 

202.0 

336 

292.3 

346 

179.6 

267 

44.3 

209 

SO.  7 

204 

87.5 

147 

123.6 

146 

173-3 

189 

126.5 

141 

130.0 

154 

132.0 

160 

122.7 

146 

125.9 

149 

116.4 

138 

118.9 

15^1 

330 

141 

14-3 

137 

13.0 

158 

344-5 

367 

67.3 

265 

149-9 

245 

26.9 

225 

109.2 

365 

20.4 

181 

126.4 

128 

270.1 

293 

30.0 

260 

41-5 

360 

Professor  Egleston's  standard  of  nutrition  is  high.  He  places  the 
daily  allowance  of  nutritive  material  at  700  gm.,  divided  as  follows: 
Carbohydrates,  400  gm.;  fats,  150  gm. ;  proteid,  150  gm., — yielding 
in  all  3650  calories. 


FOOD   VALUES    OF    EDIBLE    PORTIONS    OF    DIET. 


229 


PERCENTAGE  COMPOSITION  OF  EDIBLE  PORTIONS  OF  GARRISON 
RATIO'S.— {Captain   C.  E.   Woodruff,  M.D.,  Assista7it  Surgeoti,  U.  S.  A.) 


Water. 


Protein. 


Carbo- 
hydrates. 


Salts. 


Energy 

Calories, 

per  lb. 


Bacon,  fat,      

Beans,  

Pork,  salt  and  fat,  .  . 
Sugar,  ground,  .... 
Sugar,  brown  issue,   .    . 

Flour,      

Beef, 

Potatoes, 

Onions, 

Oatmeal, 

Cornmeal,        ..... 
Canned  apples,  .... 
Dried  apples,      ... 
Tapioca  or  corn-starch. 

Butter, 

Syrup,      

Lard, 

Rice, 

Canned  corn,  .... 
Canned  tomatoes,  .  .  . 
Macaroni  and  vermicelli. 
Milk,  fresh,  .  ... 
Milk,  condensed,   .    .    . 

Peas, 

Raisins, 

Cheese, . 

Prunes,    

Cabbage,     

Ham, 

Apricots,  canned,  .    .    . 

Barley 

Chocolatf,       

Sausage,      

Oysters, 

Salmon,  canned,    .    .    . 

Crabs, 

Crackers, 


20.0 
12.6 
12. 1 

2.0 

3-0 
12.5 

55-0 
78.9 

87.9 
7.6 
150 
83.2 
25.0 
2.0 
10.5 

43-7 
12.0 
12.4 

81.3 
96.0 

131 
14. 1 
25.0 
12.3 

40.0 

35-0 
30.0 
92.0 

41-5 
50.0 

12.0 
41.2 
87.1 
63.6 


8.00 

23.10 

0.90 


11.00 
17.10 
2.10 
1.4 
15.10 
9.20 
0.20 
0.90 

1. 00 

0.60 

7-4 
2.80 
0.80 
9.00 
0.843 
17.00 
26.70 
0.40 

33-00 
2.50 
2.10 

16.7 
2.00 

13.00 

20.00 

13.80 
6.00 

21.60 

150 

10.3 


69-5 

2.0 

82.8 


i.o 
27.0 

O.  I 

0-3 
7-1 

3-8 
0.4 
1.8 

85.0 

83.4 
0.4 
I.I 
0.4 

03 
o  802 

II. o 

1-7 
22.0 

0.6 
39-1 

2.7 
50.0 
42.8 

1.2 

13-4 
1.0 

9-4 


59-2 

97.8 
96.5 
74-9 

17.9 
10. 1 

68.2 
70.6 
15-9 
71-5 
97.8 

0.5 
55-0 

79-4 
13.2 

2-5 

76.8 

1.069 
44.00 
56.40 
24.00 

5.00 
12.0 

5-5 

30.0 
76.0 

lO.O 

3-7 


70.5 


2-5 

31 

4.2 
0.2 
0-5 
0-5 
0.9 
1.0 
0.6 
2.0 
1.4 
0-3 
1-4 
0.2 

3-0 
2-3 
4.0 
0.4 
0.6 

03 

0.8 
0.164 

3-0 
2.9 
0.6 
50 
0.6 
I.I 
2.7 
0.6 
3-0 
4.0 
2.2 
2.0 
1-4 


3,080 
1,615 

3.510 
1,820 

1,795 
1,644 
1,460 

375 

225 

1,850 

1,645 

315 
1,418 
1,820 

3,615 
1,023 

3,570 
1,630 

345 

80 

1,406 

418 
1,595 
1,565 

440 
1,600 

140 

155 

1,960 
460 
1,800 
2,650 
2,065 
230 

965 

526 

1,900 


Church  furnishes  the  following  table  showing  the  number  of  tons 
which  it  is  calculated  could  be  raised  one  foot  by  the  complete  com- 
bustion of  a  single  pound  of  each  kind  of  food.  In  the  body  only 
about  a  fifth  of  this  energ}^  would  develop  work,  the  rest  going  into 
heat  production: 


I  pound  beef-fat 
I  pound  oatmeal 
I  pound  gelatin 
I  pound  lean  beef 
I  pound  potatoes 
I  pound  milk 
I  pound  ground  rice 


raises  5,649  tons  I  foot  high. 

2,439 
2,270 

885 

618 

390 
2,330 


230 


DIETETIC   KITCHEN. 


CHAPTER  II. 
DIETETIC  KITCHEN.— DIET  LISTS. 

In  the  following  pages  we  give  the  diet  orders  of  Penzoldt,  which 
agree  essentially  with  those  mentioned  by  Leube,  but  have  this 
advantage  over  the  latter,  that  they  contain  at  the  same  time  the 
permissible  quantities  of  each  article  of  food,  and  are  also  expanded 
in  other  directions. 

The  following  diet  list,  consisting  of  four  different  kinds  of  diet, 
is,  like  that  of  Leube,  especially  intended  to  be  a  basis  for  a  mild 
dietetic  treatment  in  cases  of  diseases  of  the  stomach  in  general 
(the  so-called  ulcer  cure  of  Leube).  By  means  of  a  gradual  transi- 
tion from  a  very  light  to  a  stronger  and  richer  diet,  it  endeavors 
not  to  tax  the  diseased  organ  in  the  beginning,  and  gradually  to 
accustom  it  to  increased  service. 

It  is  self-evident  that  this  diet  list  may  not  with  impunity  be 
extended  in  the  same  manner  to  all  diseases  of  the  stomach.  Accord- 
ing to  the  state  of  the  secretion,  the  peristalsis,  and  of  sensation, 
other  problems  concerning  the  diet  may  arise.  We  shall  revert  to 
the  special  details  of  the  several  forms  of  disease  when  we  come  to 
them.  It  is  necessary  only  to  give  the  principal  rules  for  the  chief 
types  of  diseases  of  the  stomach  in  this  chapter. 


PENZOLDT' S  DIET  ORDERS  FOR  GRADUAL  TRAINING  OF  THE 
DIGESTIVE  CAPACITY. 

FIRST   DIET  (ABOUT  TEN  DAYS). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  to  be  Taken. 

Bouillon. 

250  gm.,  X 
liter. 

To  be  made  from 
beef. 

Lean,   very   little 
salt,  or  none  at 
all. 

Slowly. 

Cow's-milk. 

250  gm.,  X 
liter. 

Well   boiled,  or 
sterilized 
(Soxhlet's  ap- 
paratus). 

Pure    milk,     or 
eventually       J^ 
lime-water    and 
Yj,  milk. 

Eventually  with 
a  little  tea. 

Eggs. 

One  or  two. 

Very  soft,  merely 
warmed  or  raw. 

Fresh. 

If  raw,  stir  into 
the  warm,  not 
boiling,  bouil- 
lon. 

pEnzoldt's  diet  orders. 


231 


Penzoldt's  Diet  Orders  for  Gradual  Training  of  the  Digestive  Capacity. — 
First  Diet  (About  Ten  Days)  [Continued). 


Largest 

Foods  or  Drinks.    Quantity  at        Preparation. 
One  Time. 


Meat  solution    30-40  gm. 
(Leube  -  Rosen- 
thal'si . 


Cakes   (Albert 
biscuits). 


Water. 


Six. 


y%  liter. 


See  Dietetic  Kit- 
chen. 


Character. 


1 H  ow  TO  BE  Taken. 


It  may  have  only  ;  By  teaspoonfuls 
a  faint  odor  of  or  stirred  up  in- 
bouillon.  to  bouillon. 


Without  sugar. 


Not  soaked  or 
softened,  but  to 
be  well  masti- 
cated and  in- 
salivated. 


Ordinary  or  nat- 
ural carbonated, 
contain  ing  a 
little  carbonic 
acid  (Selters), 
Saratoga  Vichy, 
Londonderry 
Lithia,  Poland. 


Not  too  cold. 


SECOND  DIET  (ABOUT  TEN  DAYS). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character.         How  to  be  Taken. 

Calt's-brain. 

100  gm. 

Boiled. 

To  be  freed  from 
all     membranes 
and  fiber. 

Preferably  in  the 
bouillon. 

Sweetbread 
(thymus  gland). 

100  gm. 

Boiled. 

Similar  to  above, 
especially  to   be 
peeled  carefully. 

Similarly  to 
above. 

Pigeons. 

One. 

Boiled. 

Only  young  ones, 
without     skin  , 
tendons,  and  the 
like. 

Similarly  to 
above. 

Chickens. 

One,  the  size 
of  a  pigeon. 

Boiled. 

Like    above     (no 
fattened     chick 
ens). 

Similarly  to 
above. 

Raw  beef. 

100  gm. 

Finely    chopped 
or    scraped, 
with     a     little 
salt. 

To  be  taken  from 
the  fillet  (tender- 
loin). 

To  be  eaten  with 
crackers. 

Raw     beef    sau- 
sage. 

100  gm. 

Without      addi- 
tions. 

A  little  smoked. 

Similarly  to  pre- 
ceding. 

Tapioca.  ' 

30  gm. 

Cooked    to    a 
homogeneous 
gruel     with 
milk. 

16 


232 


DIETETIC   KITCHEN. 


Penzoldt's  Diet  Orders  for  Gradual  Training  of  the  Digestive  Capacity 

( Continued ) . 

THIRD  DIET  (ABOUT  EIGHT  DAYS). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  TO  BE  Taken. 

Pigeon. 

One. 

To  be  fried  with 
fresh  butter, 
not  too  much. 

Only  young  ones, 
without    skin, 
etc. 

Without  sauce. 

Chicken. 

One. 

Like  above. 

Like  above. 

Like  above. 

Beefsteak. 

ICO  gm. 

With  fresh  but- 
ter,   half    raw 
(English). 

The     meat    from 
the  fillet,  or  ten- 
derloin ,     well 
pounded. 

Like  above. 

Ham. 

loo  gm. 

Raw,     scraped 
fine. 

Smoked,    not    With      wheat 
strong,    without       bread, 
bones,    the    so- 
called  "  Lachs-  1 
schinken."           i 

French  roll,  toast, 

5°  gm. 

Baked  crisp. 

Stale    (rolls    and 

To    be    chewed 

or  Freiberg 
pretzel. 

Potatoes. 


the  like). 


50  gm. 


Cauliflower.  '  50  gm. 


a.  As  puree,  be- 
ing forced 
through  a 
strainer. 

b.  As  salt  pota- 
toes, mashed. 


The  potatoes  must 
be  mealy, 
crumbling  when 
mashed. 


To  be  cooked  in 
salt  water  as 
vegetables. 


Only  the    "flow- 
ers' '  to  be  used. 


very  carefully 
and  to  be  well 
salivated. 


FOURTH  DIET  (ABOUT  EIGHT  TO  FOURTEEN  DAYS). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  TO  BE  Taken. 

Venison.                   100  gm. 

1 

Roast. 

Saddle,  hung,  not 
gamy,     without 
high  flavor. 

Partridge. 

One. 

Roast,     without 
lard. 

Young  birds,  with 
skin,     tendons, 
feet,   etc.,   re- 
moved,    after 
having  hung  in 
pure     cold     air 
for    twenty-four 
hours. 

Roast  beef. 

100  gm. 

Fried  until  red. 

From  wel  1  -  fed 
cattle,  pounded. 

WaiTu  or  cold. 

DIBT   LISTS. 


233 


Penzoldt's  Diet  Ordhrs  for  Gradual  Training  of  the  Digestive  Capacity. — 
Fourth  Diet  (About  Eight  to  Fourteen  Days)  {Continued). 


Foods  OR  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  TO  BE  Taken. 

Fillet. 

100  gm. 

In  same  manner 
as  the  above. 

In    same    manner 
as  the  above. 

In  same  manner 
as  the  above. 

Veal. 

100  gm. 

Roast. 

Saddle  or  leg. 

Finely  cut. 

Pike.              ] 
Perch-pike.    ! 
Carp.               1 
Trout.            J 

100  gm. 

Boiled     in     salt 
water    without 
any  additions. 

Carefully   remove 
the  bones. 

In  fish  sauce. 

Caviar. 

50  gm. 

Raw. 

Russian        caviar 
with  but  a  little 
salt  in  it. 

Asparagus. 

50  gm. 

Boiled. 

Soft,  without  the 
hard  portions. 

With  a  little 
melted  butter. 

Rice. 

50  gm. 

As  gruel,  forced 
through      a 
strainer. 

Soft,  boiling  rice. 

Likewise. 

Poached  eggs. 

Two  eggs. 

With    a    little 
fresh  butter. 

With  salt. 

Omelette    souffle 
(Auflauf). 

Two  eggs. 

With    about    20 
gm.  sugar. 

Must  rise  well. 

To  be  eaten  at 
once. 

Stewed  fruits. 

50  gm. 

Fresh  boiled, 
forced  through 
a  strainer. 

Freed  of  all  skins 
and  seeds. 

Red  wine. 

100  gm. 

Light,  pure  Bor- 
deaux, or  reli- 
able California. 

Or  any  similar 
kind  of  pure  red 
wine. 

Slightly  warmed. 

All  of  these  foods  should  be  prepared  according  to  directions  given 
in  the  "Dietetic  Cooking." 


DIET  LIST  OF  EWALD  FOR  CHRONIC  GASTRITIS. 

8  A.  M. — 150  to  200  gm.  of  tea,  with  100  gm.  of  stale  wheat  bread,  toast,  or 
zwieback. 

10  A.  M. — 50  gm.  of  wheat  bread,  10  gm.  of  butter,  50  gm.  of  cold  meat  or  ham, 
and  either  one  glass  of  light  wine  or  ^  of  a  liter  of  milk. 

2  p.  M. — 150  to  200  gm.  of  water,  milk,  or  bouillon  of  white  meats;  100  to  125 
gm.  of  meat  or  fish,  30  to  100  gm.  of  vegetables,  80  gm.  compote. 

4.30  p.  M. — Yi  of  a  liter  of  warm  milk,  chocolate,  or  one-half  milk  and  one- 
half  coffee. 

7  to  8  p.  M. — 300  gm.  of  soup,  50  gm.  of  wheat  bread,  10  gm,  of  butter. 

10  p.  M. — Occasionally  50  gm.  of  wheat  bread,  biscuit,  or  zwieback;  one  cup 
of  coffee. 


234  DIETETIC    KITCHEN. 

Boas  gives  two  lists;  the  following  contains  the  better  and  richer 
diet: 

Calories. 
8  A.  M. — 200  gm.  of  milk,  with  40  gm.  of  cocoa  and  30  gm.  of  sugar,  .    .  462 

50  gm.  of  cakes,  or  50  gm.  of  zwieback,  either  one, 187 

10  A.  M. — 50  gm.  of  wheat  bread  with  30  gm.  of  butter,       343 

100  gm.  of  calf 's-brain  (or  100  gm.  of  sweetbread,  90  calories),      .    .  140 
Or  100  gm.  of  broiled  pike,  71.75  calories. 

12  M. — Soup  of  30  gm.  of  tapioca,  10  gm.  of  butter,  i  &gg 282 

100  gm.  of  noodles 352 

Or  100  gm.  of  spinach,  165  calories;  loo  gm.  of  bean  puree, 
193  calories;  100  gm.  of  carrots,  40  calories;  50  gm.  of 
potato  puree,  63.7  calories. 

100  gm.  of  breast  meat  of  young  chicken, 106.4 

100  gm.  of  veal  cutlets  (250  calories),  or,  in  its  place,  100  gm.  of 
broiled  veal,  pigeon,  venison,  or  fish. 

100  gm.  of  farina  or  omelette,  or  egg-pancake, 288 

3  P.  M. — 100  gm.  of  milk,  with  20  gm.  of  sugar,  flavored  with  tea,     .    .    .  147 

25  gm.  of  cakes, 93.5 

7  P.  M. — 50  gm.  of  wheat  bread,  130  gm.  of  butter 343 

50  gm.  of  scraped  raw  beef, 459-5 

3203.4 

HEMMETER'S    DIET  LIST  FOR  CHRONIC  GASTRITIS  WITH  UNIM- 
PAIRED MOTILITY  AND  INTESTINAL  DIGESTION. 

Also  Available   for  Lowered  Nutrition  where   Intestinal  Functions  are 

Normal. 
7.30  a.  m. — If  the  bowels  are  regular,  X  of  a  pint  of  hot  normal  saline  solution. 
If  the  bowels  are  constipated,  a  pint  of  cold  Saratoga  Vichy,  Bedford 
Magnesia  Spring,  or  plain  cold  water. 

Calories. 
Breakfast,  8  a.  m. — 3^  ounces  or  100  gm.  of  farina,  boiled  with  milk,    .  127 
Or  100  gm.  of  cerealin,  boiled  with  milk ; 

Or  100  gm.  of  breakfast  wheat  (strained),  boiled  with  milk. 

Calories. 

One  soft-boiled  &g^ 80 

Two  ounces  of  wheat  bread,  toasted 156 

One  ounce  of  best  fresh  butter 212 

One  cup  of  wheat  coffee  (made  of  100  gm.  of  roasted  choice  wheat, 
250  c.c.  of  boiling  water,  and  1 50  gm.  of  milk).    Instead  of  this 

the  same  portions  of  tea  and  milk  or  cocoa  can  be  used,  .    .    .  100 

Sugar,  ID  gm.  (2)^  drams) 4° 

The  farina  or  cerealin  will  taste  better  if  eaten  with  a  roasted 
apple. 

As  the  digestive  power  improves,  the  egg  is  served  in  form  of 
omelette,  or  poached,  on  toast. 


DIET  LISTS.  235 

Calories. 

10  30  A.  M. — 100  gm.  of  scraped  ham  (3^  ounces) 120 

30  gm.  of  crackers  or  toast  (one  ounce), 107 

226  gm.  or  eight  ounces  of  broth.     Instead  of  broth,  milk,  kefyr, 

and  matzoon  may  be  permitted  in  the  same  quantity,    ....        306 
Dinner,  i  p.  m. — Soup  made  of  250  gm.  or  eight  ounces  of  bouillon,  30 
gm.  or  one  ounce  of  rice  or  tapioca,  10  gm.  or  2)^  ounces  of 
butter,  and  one  ^gg, 282 

In  case  of  much  weakness  and  emaciation,  ^  of  a  tablespoonful 
of  somatose  should  be  added. 

The  patient  must  not  be  aware  of  the  addition  of  artificial  foods. 

Calo7-ies. 
120  gm.  of  breast  meat  of  broiled  fowl, 228 

Or  scraped  tenderloin  formed  into  patties  and  broiled  ; 

Or  steamed  or  broiled  bluefish,  trout,  white  or  pellow  perch  ; 

Or  broiled  rockfish  or  sweetbreads. 

50  gm.  or  two  ounces  of  potato  puree 637 

100  gm.  or  3^  ounces  of  carrots,  steamed 40 

Or  100  gm.  of  puree  of  beans  or  peas; 

Or  100  gm.  of  strained  tomato  puree. 
TOO  gm.  of  finely  divided  spinach. 
One  cup  custard  made  of  two  eggs, 160 

Or,  instead  of  this,  100  grs.  of  sherry  gelatin,  or  stewed  apples, 
or  plums,  or  rice  in  form  of  very  light  pudding  made  with 
slices  of  apple,  no  raisins. 
One  glass  (100  gm.  or  3^  ounces)  of  Hungarian  Tokay  (J.  Palug- 

yay  &  Sons,  Pressburg) 50 

This  list  is  made  intentionally  abundant  in  order  to  permit  of 
latitude  in  making  a  selection. 

Instead  of  the  meats  given,  the  patient  may,  for  a  change,  be 
allowed  broiled  pigeon  or  venison,  which  must  not  be  gamy;  also 
meat  dumplings  of  scraped  beef,  scraped  pork  made  into  balls  with 
bread  crumbs,  zwieback  crumbs,  o^gg,  and  butter,  cooked  in  bouil- 
lon, and  a  separate  sauce  is  made  and  flavored  with  scraped  sar- 
delles. 

Calories. 
3  P.  M. — One  cup  of  chocolate  made  with  30  gm.  or  i  ounce  of  breakfast 

cocoa,  or  v.  Mehring's  Kraft-chocolate,  and  ^  of  a  pint  of  milk,      135-5 
30  gm.  of  crackers,  coffee-cake  without   grated   nuts,  cinnamon 

shortcake  with  but  the  faintest  trace  of  cinnamon, 107 

If  the  sweet  chocolate  is  not  agreeable,  plain  milk,  or  a  glass  of 
light  Rhine  wine  with  crackers,  is  allowable.  Coffee  in  small  quan- 
tities may  be  added  to  the  milk  at  this  hour. 


236 


Di^T^Tic  kitche;n. 


Calories. 
Supper,  6.30  p.  m. — Broiled,  panned,  or  raw  oysters,  240  gm.  or  eight 

ounces, 70 

If  there  is  sub-  or  anacidity,  the  addition  of  a  little  grated  horse- 
radish, lemon-juice,  or  catsup  to  the  raw  oysters  should  not  be 
forbidden. 

Crackers,  two  ounces  or  60  gm., 107 

Butter,  one  ounce  or  30  gm., 212 

^  of  a  pint  of  reliable  Rhine  wine, 50 

Or  ^  of  a  pint  of  imported  beer,  or  ^  of  a  pint  of  tea  and 
milk.      Instead   of   the  oysters,   little  neck  clams,  fresh 
scraped  beef,  finely  cut  roast  lamb  or  beef,  cold,  smoked 
chipped  beef,  or  smoked  tongue  will  answer. 
Note. — If  the  gastritis  is  evidently  due  to  abuse  of  alcohol,  the  wines  and 
beer  must  be  excluded. 


BILL  OF   FARE  FOR   CHRONIC   CATARRH   OF   THE   STOMACH,  WITH 
THE  DIGESTION  OF  THE  STOMACH  ONLY,  REDUCED.— ( f^^^cr^/^.) 


Albumin. 

Fat             Carbo- 
hydrate. 

I 

Alcohol. 

Morning  : 

150  gm.  of  pepton  cocoa,     .... 
25  gm.  of  butter  (on  toasted  roll),     . 
Forenoon : 

I  soft  e?? 

8.00 
0.18 

6.00 

12.50 

28.00 

2.14 

8.00 
0.18 

6.00 
25.00 

9.00 

6.0 
20.8 

5-0 

0.3 
13-5 
0.4 

6.0 
20.8 

5-0 
8.0 

03 
1-5 

7-50 
0.15 

18.00 

1.80 

16.30 

7-50 
0.15 

76.70 

6.00 
63.90 

Noon  : 

200  gm.  of  oatmeal  soup, 

150  gm.  of  fowl, 

200  gm.  of  carrot, •    •    • 

Afternoon : 

150  gm.  of  pepton  cocoa, 

25  gm.  of  butter  and  Albert  biscuit 

or  banquet  crackers, 

Evening  : 

100  gm.  of  scraped  ham, 

100   gm.    of  macaroni,    with    toasted 

bread  crumbs, 

During  the  Day  : 

16.0 

75  gm.  of  toast, 

9.00 

Total,      

117.20 

94.6 

236.01 

16.0 

Calories,  about 

480 

890 

970 

100 

Entire  combustion  value  about  2440  calories. 


DIET  LISTS.  237 

BILL  OF  FARE  FOR  ATROPHIC  CATARRH.— {IVege/e-Fenzo/dL) 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Morning: 

150  gm.  of  maltoleguminose  cocoa, 
Forenoon: 

150  gm.  of  wine, 

20  gm.  of  butter  (on  toasted  bread). 
Noon  : 

lOD  gm.  of  maltoleguminose  soup,  , 

100  gm.  of  scraped  beefsteak,  .    .    . 

100  gm.  of  mashed  potatoes,    .    .    . 

10  gm.  of  malt  extract, 

Afternoon  : 

I  cup  of  tea  (with  toast), 

20  gm.  of  butter, 

30  gm.  of  honey, 

Evening  : 

250  gm.  of  rice  mush, 

During  the  Day  : 

75  gm.  of  toast  (or  toasted  bread),  . 
10  o'clock  at  Night  : 

250  gm.  of  milk, 

10  gm.  of  cognac  brandy,    .... 

Total,      


Calories,  about 


6.00 


0.15 

2.60 

20.00 

3.10 

0.50 


0.15 

0.40 


9.00 

8.70 


72.70 


300 


4.00 

16.60 

o.io 
6.00 
0.50 

16.60 

8.25 
1.50 
9-30 


13-50 

4.00 
0.12 

6.20 

21.30 
5-50 


0.12 
22.00 

71.00 

63.90 


62. 85 
580 


219.64 


920 


7.0 


19.0 


130 


Entire  combustion  value  about  1930  calories. 


BILL  OF  FARE  FOR  ATONY  OF  THE  STOMACH,  WITH  GASTRIC 
DIGESTION   RET>VCEB.—{IVegelf.) 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Alcohol. 


Morning  : 

150  gm.  of  leguminose  cocoa, 

50  gm.  of  cream, 

Forenoon : 

I  soft  egg, 

20  gm.  of  toast, 

Noon  : 

100  gm.  of  scraped  beefsteak, 
200  gm.  of  mashed  potatoes,    .    . 
20  gm.  of  malt  extract,  .    .    .    . 
Afternoon  : 

150  gm.  of  leguminose  cocoa,  .    . 

50  gm.  of  cream, 

Evening  : 

250'gm.  of  tapioca  pulp,  .    .    .    . 
15  gm.  of  diastase  malt  extract, 
During  the  Day  : 

50  gm.  of  toast, 


6.0 

1.8 

6.0 

2-5 

I7.I 

4.2 

I.O 

6.0 

1.8 

12.0 
0.8 

6.0 


4.0 
133 

5-0 
0.4 

6.0 
2.7 


4.0 
13-3 

8.0 


13-5 
1.8 


ISO 


42.6 

II. o 


135 

1.8 


II. o 

9.0 

3S-0 


238  die;te;tic  kitchen. 

Bill  of  Fare  for  Atony  of  the  Stomach,  with  Gastric  Digestion 
Reduced. — ( Wegele)  {Continued). 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

10  o'clock  at  Night: 

200  gm.  of  milk, .    . 

10  gm.  of  cognac, 

6.4 

7.2 

9.6 

'e'.p' 

Total, 

71.6 

64.9 

163.8 

6.9 

Calories,  about 

290 

600 

670 

50 

Total  combustion  value  about  1610  calories. 

At  noon,  of  course,  other  kinds  of  meat  could  be  chosen,  such  as 
fowl  or  game ;  likewise  at  night  rice  or  thick  gruel. 

With  fermentation  of  the  stomach,  however,  the  following  bill  of 
fare  had  best  be  used  after  a  few  days : 

Morning: 

too  gm.  of  scraped  ham  (can)  or  smoked  meat,  and  20  gm.  of  bread  crust. 
Forenoon : 

One  soft  egg  and  20  gm.  of  bread  crust  or  toast. 
Noon  : 

100  gm.  of  scraped  beefsteak  and  scrambled  eggs  (two). 
Afternoon : 

Same  as  forenoon. 
Evening  : 

Same  as  noon. 

Two  clysters  of  ^  to  i^  per  cent,  common  salt  solution. 


HEMMETER'S  DIETARY  FOR  ANACID  DILATATION. 

Calories. 

7.30  A.  M. — Lavage  with  NaCl  solution,  or  a  decinormal  solution  of  HCI. 

8  a.m. — Cerealin  with  cream,  150  gm., 395 

Mosquera  beef  chocolate,  200  gm 140 

Malt  extract,  10  gm.,      24.5 

10  A.  M. — Toast  or  aleuronat  bread  (see  dietetic  directions),  60  gm.,      .    .  135 
Butter,  20  gm 163 

12  M. — Boiled  round  of  beef,  150  gm 440 

Mashed  potatoes,  50  gm 63 

Spinach  or  carrots,  100  gm 165.5 

In  place  of  these,  purees  of  peas,  beans,  lentils,  or  turnips  are 
allowed. 
Omelette  souffle,  100  gm 244 

3  p.  m'. — 100  gm.  of  tea,  50  gm.  of  Albert  biscuits,  10  gm.  of  milk,   .    .    .  254 


DIHT  LISTS.  239 

Calories. 

J  P_  M. — 100  gm.  of  scraped  ham  in  omelette, 244 

Or  60  gm.  of  scraped  ham  (262  calories). 

200  gm.  of  farina  with  milk 43^ 

60  gm.  of  toast,  20  gm.  of  butter 298 

9.30  p.  M. — Milk,  300  c.c, 2°2 

Two  ounces  of  banquet  crackers  or  Albert  biscuits, 200 

Or  in  place  of  the  milk  a  glass  (two  ounces)  of  approved  Tokay 
or  Malaga. 


BILL  OF  FARE  FOR  ATONY  OF  THE  STOMACH,  WITH  THE  PRODUCTION 
OF  HYDROCHLORIC  ACID  SUSTAINED  OR  INCREASED.— ( ?fV^/^.) 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning  : 

150  gm.  of  pepton  cocoa, 

50  gm.  of  cream,  ^ 

Forenoon : 

30  gm.  of  French  roll, 

8.0 

1.8 

3-0 

12.5 

6.0 

21.0 

4.2 

8.0 
1.8 

21.0 
9.0 

6.0 
13-3 

0.2 
4.0 
5-0 

8.0 
2.7 

6.0 
13-3 

8.0 
6.6 

1.6 

7-S 
1.8 

20.0 

42.6 

7-5 
1.8 

'28.6 

3-3 
41.0 

Noon  : 

120  gm.  of  roast  meat, 

200  gm.  of  mashed  potatoes,    .... 

Afternoon  : 

150  gm.  of  pepton  cocoa, 

50  gm.  of  cream,      

Evening  : 

120  gm.  of  cold  roast  meat,      .... 
200  gm.  of  rice, 

10  o'clock  : 

7.8 

During  the  Day  : 

6.5 

Total,          

102.8 

74-7 

159.1 

7.8 

Calories,  about 

420 

700 

640 

55 

Total  combustion  value  about  1815  calories. 


Instead  of  ham,  caviar  and  butter  with  slices  of  toasted  roll,  or 
scrambled  eggs  with  smoked  meat,  may  be  given  in  the  forenoon. 
At  noon,  beefsteak,  fillet,  game,  or  fowl  is  allowed,  and  for  side 
dishes  some  mashed  carrots  or  spinach.  At  night,  calf's-foot  jelly 
and  omelette  souffle. 

In  convalescence,  10  to  15  gm.  of  condensed  milk  or  malt  extract 
three  times  daily  after  meals  can  be  prescribed,  through  which  the 
nutritive  value  of  this  diet  is  considerably  increased. 


240 


DIETETIC   KITCHEN. 


BILL  OF  FARE  FOR  ENLARGEMENT  OF  THE  STOMACH  WITH 
STENOTIC    APPEARANCES.— ( Wegele.) 


ALBUMIN.    ^           FAT.              H^^^^°-E.        ALCOHOL. 

Morning  : 

100  gm.  of  scraped  ham, 

Tea  with  50  gm.  of  cream, 

Forenoon : 

2  eges, 

25.0 

1.8 
12.0 

8.0                       

13-3                1-8 

lo.o           ...           ... 

20  gm.  of  sugar, 

ID  gm.  of  cognac,       

1-5 

0-5 

n-3 

1-5 
4-3 

1.2 

16.0          .    .    , 
.    .    .            13-8 

Noon  : 

100  gm.  of  scraped  beefsteak,  .    .    .    . 

100  gm.  of  mashed  potatoes,    .... 
Afternoon : 

Tea  with  50  gm.  of  cream, 

Evening  : 

100  gm.  of  roast  chicken  (hashed), 

100  gm.  of  flour  puff-paste, 

During  the  Day  : 

80  gm.  of  toast, 

20.7 
3-1 

1.8 

20.7 
4.2 

8-5 

21.3          .    .    . 
1.8          ... 

22.0          ... 

■^^.o          .    .    . 

Night  : 

200  pm.  of  milk, 

6.4          !                 7.2                               9.6                      ... 

Total,       

104.2                       60.8                       127.5                        13-8 

Calories,  about 

427 

565 

722              100 

Total  combustion  value  about  1 8 14  calories. 


With  this  bill  of  fare  it  is  most  difficult  to  have  a  variety.  Beef- 
steak scraped  fine  from  lean  meat,  chicken,  pigeon,  lean  ham,  smoked 
meat,  cold  roast  beef,  and  fillet  are  recommended. 

In  the  evening  one  may  often  ser\^e  also  calf's-foot  jelly,  tapioca, 
or  milk  jelly.  With  occasional  improvement  condensed  milk,  cream, 
malt  extract,  and  milk  jellies  may  be  tried  by  spoonfuls  between 
meals.  Besides  these  a  nutritive  clyster  (following  a  cleansing 
enema)  is  to  be  given  twice  a  day  in  these  severe  cases.  With  pro- 
nounced stenosis,  prompt  operation  is  necessary;  where  this  is  im- 
possible or  refused,  rectal  feeding  is  preferable  to  feeding  by  the 
stomach. 

One  may  waive  the  somewhat  tedious  meat-pancreas  clysters, 
when  a  considerable  quantity  of  meat  is  taken  in  per  os,  and  employ 
either  Ewald's  or  Boas'  method  of  rectal  alimentation,  since  accord- 
ing to  the  investigations  of  Eichhorst  ("Pfliiger's  Archiv,"  Bd.  iv, 
1871),  Ewald  ("Zeitschrift  f.  klin.  Med.,"  Bd.  xii,  1887),  and  Huber 
("Deutsch.  Archiv  f.  khn.  Med.,"  Bd.  XLVii),  the  digestion  of  the 


DIET   LISTS. 


241 


albumen  of  eggs  and  milk  proceeds  very  well  without  previous  pep- 
tonization in  the  rectum,  while  it  is  considerably  increased  by  the 
addition  of  common  salt  (one  gm.  to  one  egg)  (see  chapter  on  Rectal 
Alimentation).  Boas  ("Diagnostik  und  Therapie  der  Magenkrank- 
heiten,"  zweite  Aufl.,  1891,  S.  244)  has  followed  out  rectal  nutrition 
for  ten  to  fourteen  days,  in  cases  of  severe  gastrectasia  with  symp- 
toms of  fermentation,  and  attained  not  only  the  disappearance  of 
the  symptoms  of  fermentation  and  a  considerably  better  general 
state  of  health,  but  also  temporary  increase  in  weight, — a  success 
which  lasted  from  three  to  four  months. 

If   to  the  preceding   bill  of   fare  two  more  nutritive  clysters  are 
added,  the  patient  receives : 


Albumin. 

4  esfes 

20.0 

100  gm.  of  red  wine, 

Total, 

20.0 

Calories, 

82 

Fat. 


24.0 


24.0 


224 


Carbo- 
hydrate. 


3-3 


3-3 


31 


Alcohol. 


7.8 


7.8 


54 


Total  combustion  value  about  391  calories. 

If  we  assume  that  of  this  only  ten  gm.  of  albumen,  two  gm.  of 
carbohydrate,  ten  gm.  of  fat,  and  four  gm.  of  alcohol  should  attain 
resorption,  we  would  obtain  a  total  combustion  value  of  about  175 
calories. 

With  two  nutritive  clysters,  according  to  Boas,  the  following 
increase  would  be  attained : 


500  gm.  of  milk,      .... 

4  eggs,       

30  gm.  of  red  wine,     .    .    . 
40  gm.  of  leguminose  flour, 

Total 


Albu.min. 


17.0 
24.0 


49.8 


18.2 
20.0 

'  3.6 


41.8 


Carbo- 
hydrate. 


24.2 
25.0 


49.2 


Alcohol. 


If  half  be  assumed  as  resorbed,  then  there  would  be  an  addition 
of  about  25  gm.  of  albumin,  about  20  gm.  of  fat,  about  25  gm.  of 
carbohydrate,  about  one  gm.  of  alcohol.  This  would  give  a  total 
combustion  value  of  about  1 850  calories  (Wegele). 


242 


die;te;tic  kitchen. 


BILL  OF    FARE   FOR    GASTRIC  CARCINOMA  WITHOUT    PERCEPTIBLE 
STENOTIC  APPEARANCES.— (fT^g-^/^.) 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning  : 

150  gm.  of  maltoleguminose  cocoa,  . 
Forenoon : 

200  gm.  of  kefyr, 

Noo\: 

150  gm.  of  maltoleguminose  soup,    . 

100  gm.  of  scraped  beefsteak,  .  .  . 
Afternoon : 

150  gm.  of  maltoleguminose  cocoa,  . 
Evening  : 

100  gm.  of  scraped  ham,    .    .    .    .    . 

150  gm.  of  tapioca, 

10  o'clock  : 

200  gm.  of  kefyr, 

With  the  cocoa,  30  gm.  of  honey,    . 

With  the  kefyr,  20  gm.  of  cognac,  . 
During  the  Day  : 

6.0 

6.6 

4.0 
20.0 

6.0 

25.0 
7.0 

6.6 

0.4 

6.6 

4.0 

4.5 

0.15 
6.0 

4.0 

8.0 
5-0 

4-5 
1.0 

13-5 
3-8 
9-3 

13-5 

8.0 

3-8 
22.0 

35-0 

14.0 

Total, 

87.6 

37-1 

108.9 

15.0 

Calories,  about 

360 

350 

450 

100 

Total  combustion  value  about  1260  calories. 


For  a  change,  tea  may  be  often  given  instead  of  cocoa ;  where  kefyr 
does  not  agree  with  the  patient,  or  is  refused  by  him,  one  may  try 
condensed  milk  with  cognac  instead;  further,  one  may  let  him  eat 
butter  upon  toast,  or  toasted  bread  with  the  tea,  and  also  have 
variety  in  the  meats,  so  long  as  the  appetite  for  them  remains. 

Naturally,  in  the  last  stages  a  considerable  narrowing  of  the  list, 
both  in  quantity  and  quality,  takes  place,  and  one  must  make  the 
greatest  concessions  to  the  individual  tastes  of  the  patient.  In  the 
morning  either  cocoa  or  tea,  with  slices  of  toasted  roll  spread  with 
meat  extract  or  caviar ;  then  allow  a  little  wine  with  one  soft  egg,  or 
egg  with  cognac  and  sugar,  or  a  glass  of  champagne ;  at  noon  sweet- 
bread in  soup,  smoked  ham,  pickled  meat,  smoked  meat  (which 
foods  are  more  difficult  of  decomposition),  gruel,  rice,  mondamin 
cooked  in  milk,  according  to  taste.  In  the  afternoon,  tea  with  cognac 
or  cocoa,  and  in  the  evening  calf's-foot  jelly,  or  meat-extract  jelly, 
or  meal  soup  will  be  suitable.  In  addition,  the  nutritive  clysters 
mentioned  above.  (A  more  detailed  calculation  of  the  diet  at  this 
stage  has  little  value,  and  is  therefore  omitted.) 


DIET   LISTS. 


243 


(I)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 
TEN  T>KYS).—{Leube-Penzoldi-  Wegele.) 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Morning  : 

250  gm.  of  milk,  .... 

Two  cakes  (5  gm.  each),     . 
10  o'clock  : 

250  gm.  of  milk  or  bouillon, 

One  cake, 


12  O'CLOCK: 

150  gm.  of  bouillon, 

50  gm.  of  meat  solution  (or  one  egg), 
4  o'clock  : 

250  gm.  of  milk, 

Two  cakes,    . 

150  gm.  of  bouillon, 

50  gm.  of  meat  solution  (or  one  egg), 
Two  cakes, 


Total,      .    .    .    , 
Calories,  about 


8.50 
1. 10 


8.50 
0.60 


9.00 
0.50 

9.00 
0.25 


330 


12.0 
7-3 


12.0 
3-7 


0.75 

0.45 

0.9 

8.50 

3-00 

3-5 

8.50 

9.00 

12.0 

I. ID 

0.50 

7-3 

0-75 

0.45 

0.9 

8.50 

3.00 

3-5 

1. 10 

0.50 

7-3 

47-9 

35-65 

70.4 

330 


Total  combustion  value  about  860  calories. 


(2)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 
SEVEN  DAYS).— {Letibe- Wegele.) 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Morning  : 

250  gm.  of  milk, 
Three  cakes, 


ID  o'clock  : 

200  gm.  of  bouillon, 

One  egg, 

Noon  : 

One  boiled  pigeon, 

About  200  gm.  of  rice  in  bouillon, 
4  o'clock  : 

250  gm.  of  milk,       

Two  cakes, 


8  o'clock  : 

150  gm  of  bouillon, 
100  gm.  of  sweetbread. 


Total, 


Calories,  about 


8.5 
1.8 


3-2 
6.0 


22.0 

50 

8.5 

I.I 

6.4 

28.0 


90.5 


370 


9.00 

0.75 

4.40 
5.00 

1. 00 
2.00 

9.00 

C.50 

6.70 
0.40 


38.75 


350 


12.0 
II. I 

3-2 


0.7 

40.0 

12.0 
7-3 

9.0 


95-3 


390 


Total  combustion  value  about  iiio  calories. 


244 


diete;tic  kitchun. 


(3)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (FOR  AT  LEAST  FIVE 

T)KYS).—{Wegele.) 


Carbo- 
hydrate. 


Morning  : 

Two  cups  of  tea  or  coffee,  with  100  gm.  of  milk, 

20  gm.  of  sugar, 

Three  cakes, 


10  o'clock  : 

200  gm.  of  bouillon,     ......... 

One  egg, 

Noon  : 

200  gm.  of  soup, 

150  gm.  of  beefsteak, 

100  gm.  of  mashed  potatoes,  .... 
4  o'clock  : 

Two  cups  of  tea  with  loo  gm.  of  milk, 

20  gm.  of  sugar, 

Three  cakes, 

Evening: 

100  gm.  of  scraped  ham, 

200  gm.  of  soup, 


Total, 


Calories,  about 


3-4 
0.5 
1.8 


3-2 
6.0 


3-2 

31.0 
31 

3-4 
1.8 

25.0 

3-2 


86.1 


3.60 
0-75 

4.40 
5.00 

6. CO 
2.20 
0.85 

3.60 

0.75 

8.10 
6.00 


41.25 


350 


380 


4.8 
18.2 
II. I 

3-2 


17.0 

21.3 

4.8 

18.2 

II. I 

17.0 


126.7 


520 


Total  combustion  value  about  1250  calories. 


(4)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 

ONE  WEEK). 


Albumin. 


Carbo- 
hydrate. 


Morning  : 

Two  cups  of  tea  or  coffee,  with  loo  gm.  of  milk, 

20  gm.   of  sugar, 

One  sweetbread  (50  gm. ), 

10  o'clock  : 

200  gm.  of  bouillon, 

One  egg, 

Noon  : 

200  gm.  of  soup, 

150  gm.  of  roast  fowl, 

100  gm.  of  carrots  or  spinach, 

200  gm.  of  light  flour  food, 

4  o'clock: 

Two  cups  of  tea  or  coffee,  with  100  gm.  of  milk, 

20  gm.  of  sugar, 

One  sweetbread, 

Evening  : 

100  gm.  of  cold  roast  meat, 

250  gm.  of  tapioca, 


3-4 
0-5 
4-5 

3-2 
6.0 

3-2 
27.6 

I.O 

9.0 

3-4 
0.5 
4-5 

38.2 
7.0 


3-6 

0-5" 

4.4 
5-0 

6.0 

14.0 

0.2 

8.4 

3-6 

'  o'-s' 

2.8 
5-0 


4.8 
18.2 
29.0 

3-2 


17.0 

1-7 

8.1 

45-0 

4.8 
18.2 
29.0 


8.0 


DIET   IN    CHRONIC   DIARRHEA. 


245 


(4)  Bill  of  Fare  for   Cure  of  Ulcer  (to  be  kept  up   at   least  one  week) 

{^Continued^. 


Albumin. 

Fat. 

Carbo- 
hydrate. 

- 
10  o'clock  at  Night  : 

250  gm.  of  milk, 

8.5 

9.0 

12.0 

Total, 

120.5 

63.0 

199.0 

Calories,  about  .    .        

495 

585 

815 

Total  combustion  value  about  1900  calories. 

Instead  of  tea  or  coffee,  milk  may  also  be  served,  by  which  the 
nutritive  value  of  this  diet  is  not  inconsiderably  increased.  Con- 
cerning the  first  list  it  is  to  be  remarked  that  instead  of  meat  solution, 
eggs  may  be  given  (stirred  into  the  soup). 

Further,  in  the  second  and  third  lists  it  is  allowable  to  give  two 
or  three  soft-boiled  eggs  instead  of  meat  in  the  evening. 

The  fourth  list  may,  after  a  time,  be  quantitatively  and  qualita- 
tively expanded,  since  the  following  are  allowed:  Meats  (fillet, 
roast  beef,  beefsteak,  roast  veal  "from  the  leg,"  spring  chicken, 
pigeons,  partridges,  venison). 

Fish — pike  and  perch  (boiled)  are  allowable. 

Vegetables — mashed  potatoes,  spinach,  and  golden  turnips. 

Of  the  farinaceous  foods,  the  light  puff-paste  of  rice,  fine  oat- 
meal, tapioca,  and  omelette  souffle  come  under  consideration. 

At  evening,  mushes  with  whisked  eggs ;  preserved  or  stewed  fruits 
may  be  tried  gradually. 

Salads  are  entirely  to  be  avoided.  Wines  may  now  be  permitted 
in  small  quantities  before  meals.  By  gradual  increase  in  quantity, 
one  must  attempt  to  give  the  body  the  nourishment  necessary  for 
its  proper  maintenance. 

DIET  LIST  FOR  CHRONIC  DIARRHEA  (Severe  Qhs,^?>) .—{Wegele .) 


Alcohol. 


Morning': 

200  gm.  of  acorn  cocoa,  boiled  in  water, 

One  soft  egg, 

Forenoon : 

250  gm.  of  decoction  of  whortleberries 
(from  80  gm.  of  dried  berries) 

250  gm.  of  slimy  soup,      .    .    . 

One  egg  in  the  soup,     .... 

100  gm.  of  scraped  meat  (lean), 
50  gm.  of  rice  in  bouillon, 


Albumin. 

Fat. 

Carbo- 
hydrate. 

2-3 

3.60 

12.0 

6.0 

5.00 

0.6 

5-5 
6.0 

1.30 

4.00 
5.00 

.". 

20.7 
4-0 

1.50 
0.50 

38.0' 

246  DIETETIC   KITCHEN. 

Diet  List  for  Chronic  Diarrhea  (Severe  Cases). — {Wegele)  {Continued). 


Afternoon : 

250  gm.  of  whortleberry  decoction, 
Evening : 

250  gm.  of  maltoleguminose  soup,  . 

With  one  egg, 

150  gm.  of  minced  chicken,      .    .    . 
During  the  Day  : 

75  gm.  of  toast, 

200  gm.  of  whortleberry  wine,     .    . 
ID  o'clock  at  Night: 

250  gm.  of  barley  mush  (20;  250), 


Total, 


Calories,   about 


Albumin. 

Fat. 

HYDRATE. 

Alcohol. 

0.6 

1.30 

4-7 

.    .    . 

6.5 

0.25 

15-5 

6.0 

5.00 

15.0 

9.00 

12.0 

\ 

9.0 

1.50 

42.5 

•    • 

■    ■    ■ 

7.0 

17.0 

5-0 

4.00 

25.0 

.     .    . 

87.2 

42.00 

168.9 

17.0 

360 

390 

690 

120 

Total  combustion  value  about  1440  calories. 

At  the  beginning  of  convalescence  light  flour  foods  are  allowed 
at  noon;  afternoon,  instead  of  the  whortleberry  decoction,  acorn 
cocoa  may  be  substituted;  at  noon,  roast  fowl,  beefsteak,  fillet, 
roast  beef,  and  gradually  pass  over  to  the  following  list : 

DIET  LIST  FOR  CHRONIC  DIARRHEA  (Less  Severe  Qk?,^^).— {Wegele). 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Morning  : 

200  gm.  of  acorn  cocoa,    .... 

With  one  egg, 

Forenoon : 

250  gm.  of  kefyr  (four  days  old), 

Noon  : 

250  gm.  of  soup, 

With  one  egg, 

150  gm.  of  roast  chicken,      .    .    . 
200  gm.  of  mashed  potatoes,    .    . 

4  o'clock  : 

250  gm.  of  acorn  cocoa,    .... 

6  o'clock  : 

250  gm.  of  kefyr, 

8  o'clock  : 

200  gm.  of  soup, 

With  one  egg, 

100  gm.  of  sweetbread,     .    •    .    . 
10  o'clock  : 

250  gm.  of  kefyr, 


2.30 
6.00 


8.20 

5-50 

6.00 

28.00 

6.00 

2.30 

8.20 

3-30 

6.00 

28.00 

8.20 


3-6 
50 

5-7 

4.0 

5.0 

lo.o 

1-7 

3-6 

5-7 

6.0 

0-5 

5-7 


750 

1.80 
42.70 

12.00 

2.00 

17.00 


3-2 


DIET   FOR   CHRONIC    CONSTIPATION.  247 

Diet  List  for  Chronic  Diarrhea  (Less  Severe  Cases). — {Wegele)  [Continued). 


Albumin.          Fat. 

CARBO-            ATf-OHOT 
HYDRATE.  [    ALCOHOL. 

During  the  Day  : 

75  gm.  of  toast  or  toasted  bread,    .    . 

20  gm.  of  butter, 

250  gm.  of  whortleberry  wine,     .    .    . 

9.00 
0.15 

1-5 
16.6 

42.50               .      .      . 
0.12      j        ... 

8.75       1          21.5 

Total, 

127.00 

79.6 

150.25 

313 

Calories,  about 

520 

740 

615 

210 

Total  combustio  n  value  about  2080  calories. 

After  convalescence  has  begun,  have  the  acorn  cocoa  prepared 
with  milk;  add  at  noon  light  foods;  at  night  give  milk  mush  for 
a  change;  gradually  increase  the  amount  of  kefyr  given,  and  thus 
gradually  a  diet  of  about  2500  calories'  combustion  value  is  reached, 
which  is  to  be  considered  sufficient. 


DIET  LIST  FOR  CHRONIC  CONSTIPATION.— ( «^^^°-^/f. 


Albumin. 


Carbo- 
hydrate. 


Morning  : 

Before     breakfast,     Bedford     Magnesia 
Spring  Water,  ]4.  liter. 
200  gm.  of  milk  and  coffee,      .    .... 

30  gm.  of  butter, 

30  gm.  of  honey, 

100,  gm.  of  Graham  bread, 

300  gm.  of  buttermilk,       

Noon  : 

200  gm.  of  bouillon,      

200  gm.  of  mutton, 

300  gm.  of  crisped  cabbage,     .... 

200  gm.  of  plums 

300  gm.  of  white  wine  or  apple  cider, 
Afternoon : 

300  gm.  of  buttermilk, 

Evening  : 

150  gm.  of  meat, 

30  gm.  of  butter,      

300  gm.  of  stewed  apples, 

For  the  several  meals,  250  gm.  of  Graham 

bread,      

After  evening  meal,  750  gm.  of  beer,     .    . 

Total 


Calories,  about 


3.20 
0.21 
0.35 


4.40 

24.50 

0.03 


3.20 

0.15 

17.00 


12.15 

2.80 

11.20 

1. 00 

0.60 

1.20 

23.20 
4.20 

0.80 

50.50 
14.40 

0.70 
21.60 
11.60 

.  .  . 

Q.OO 

24.7 

12.15 

2.80 

11.20 

28.20 

11.00 

0. 10 

0.21 
1. 00 

24.50 

0.15 
3900 

22.50 
42.60 

2.50 
6.50 

125.00 
4.70 

*28.8' 

145-77 

194-50 

245.80 

53-5 

600 

1800 

1000 

375 

Total  combustion  value  about  3800  calories. 


17 


248  DIETETIC   KITCHEN. 

This  list  is  easily  varied  in  accordance  with  above  statements, 
and  eventually  it  may  be  diminished  along  the  entire  scale,  or  it 
may  be  changed  with  regard  to  coexistent  stomach  troubles.  For 
the  rest  it  is  to  be  noted  that  with  the  difficult  solubility  of  many 
of  the  foods  mentioned,  and  with  an  acceleration  of  digestion  brought 
about  by  the  diet  prescribed,  a  considerable  part  of  the  nutriment 
introduced  with  the  "ingesta"  will  be  only  partially  turned  to  the 
best  advantage.  Naturally,  if  the  chronic  constipation  is  due  to 
real  catarrh,  one  must  prescribe  less  irritating  food  and  give  the 
softer  vegetables,  such  as  cauliflower,  spinach,  asparagus,  carrots; 
also  the  legumes  and  preserves  more  in  form  of  purees. 


DIET  LIST   FOR    'iiYVE'RKCIDYYY.—{Boas-Wegeie-Fieischer.) 


Albumin. 


Fat. 


Carbo- 
hydrate. 


Morning  : 

100  gm.  of  tea  with  milk, 

2  soft  eggs, 

100  gm.  of  raw  ham, 

50  gm.  of  cream, 

Noon  : 

200  gm.  of  aleuronat-meal    soup   (10 
al.;  20  oatmeal ;   250  soup),      .    .    . 

150  gm.  of  beefsteak, 

200  gm.  of  mashed  potatoes,     .... 
100   gm.   of  white   wine,  mixed  with 
Saratoga  Vichy  or  Biliner  water, 
Afternoon  : 

100  gm.  of  tea, 

150  gm.  of  cream, 

Evening  : 

50  gm.  of  cold  roast  meat, 

2  scrambled  eggs, 

100  gm.  of  wine, 

For  the  several  meals,  lOO  gm.  of  aleuronat 

toast, 

10  o'clock  at  Night  : 

250  gm.  of  milk, 


3-4 
12.0 

3-6 

lO.O 

4-8 

25.0 

8.0 

2.0 

13-5 

1-7 

10.2 

58.0 

6.2 

1-7 

30 
1-7 

8.0 

42.6 

3-5 

3-4 
2.0 

3-6 

13-5 

4.8 
1.7 

8.0 


Total, 


Calories,  about 


60.2 

4.0 

12.0 

12.0 

3-5 

8.0 

28.3 

i-S 

66.7 

•  v  • 

8.5 

9.0 

12.0 

I  229.2 

85.1 

149.4 

16.0 

940 

790 

600 

112 

Total  combustion  value  about  2500  calories. 


With  the  tea  a  little  sugar  is  to  be  allowed,  and  the  white 
wine  is  usually  to  be  mixed  with  an  alkaline  acidulous  water 
not  containing   too    much    carbonic  acid   (such  as   Biliner  water). 


DIET   LIST  FOR   HYPERSECRETION. 


249 


\A/lien  convalescence  sets  in,  the  daily  amount  of   milk  is  to  be 
increased. 

DIET  LIST  FOR  HYPERSECRETION.— (  Wegele). 


Morning  : 

Tea  with  100  gm,  of  milk, 

2  soft  eggs, 

Forenoon : 

150  gm.  of  calf 's-foot  jelly, 

Noon  : 

150  gm.  of  sweetbread  in  bouillon,    .... 

250  gm.  of  tapioca  mush, 

50  gm.  of  cream, 

Afternoon : 

200  gm.  of  milk, 

Evening  : 

200  gm.  of  ham, 

2  scrambled  eggs, 

For  the  several  meals,  100  gm.  of  aleuronat  toast, 

10  P.M.  : 

100  gm.  of  milk, 

During  Night  : 

100  gm.  of  milk, 


Total,     .    .    . 
Calories,  about 


Albumin. 


3-4 
12.0 

35-0 

32.0 

12.0 

2.0 

6.8 

48.0 
12.0 
28.3 

6.5 
6.5 


900 


Fat. 


30 
lO.O 


17.0 

"  8.0* 

13-5 
6.0 

70.0 
12.0 

1-5 
6.0 
6.0 


147.0 


1360 


Carbo- 
hydrate. 


4.8 


II. o 

1-7 
9.6 


66.7 


104.8 


430 


Total  combustion  value  about  2700  calories. 


Of  course,  other  meats  than  those  mentioned  above  may  be 
chosen,  only  the  glutinous  are  particularly  to  be  selected;  event- 
ually also  scraped  meat,  ham,  etc. 

With  convalescence  go  over  to  the  preceding  list.  With  nightly 
complaints  in  consequence  of  acid  formation,  there  is  to  be  recom- 
mended, besides  milk  or  glair-water,  especially  raw  or  hard,  grated 
eggs,  and  drinking  afterward  of  alkaline  waters.  Penzoldt  recom- 
mends the  addition  of  one-fourth  to  one-third  lime-water  to  the 
milk. 

As  concerns  the  power  of  the  various  foods  to  combine  with  HCl, 
the  following  table  is  based  upon  results  obtained  experimentally 
by  Fleischer  ("Krankh.  d.  Speiserohre,  d.  Mag.  u.  d.  Darms,"  Wies- 
baden, 1896,  p.  932): 


2  50 


DIETETIC    KITCHKN. 


Meats,  ioo  gm.,  Combine  With 

Calf's-brain,  boiled, 

Liver  pudding, 

Sweetbread,  boiled, 

Mettwurst, 

Saveloy, .    . 

Black  pudding, 

Pork,  boiled, 

Ham,  boiled, 

Ham,  raw, 

Mutton,  boiled, 

Beef,  boiled, 

Veal,  boiled,     ....         

Leube-Rosenthal's  meat  solution,     .    .    . 

Other  Foods. 

Beer, 

Milk, 

Wheat  bread, 

Graham  bread, 

Black  (gray)  bread, 

Pumpernickel,       

Hand  cheese, 

Fromage  de  Brie, 

Edam  cheese, 

Brick  cheese, 

Pease  sausage, .    . 

Roquefort  cheese, 

Swiss  cheese, 

Cocoa, 


25  Per  Cent.      12^  Per 
HCl.  Cent.  HCl. 


2.6 

3-2 
3-6 
4.0 
4-4 
5-2 
6.4 
7.2 
7.6 
7.6 
8.0 


0.40 
1.44 
1.20 
1.20 
2.00 
2.80 
4.00 
5.20 
5.60 
6.80 
6.80 
8.40 
10.40 
16.40 


55-2 

6.4 

7.2 

8.0 

8.8 

10.4 

12.8 

14.4 

152 

15-2 

16.0 
17.6 
17.6 


0.80 

2.88 

2.40 

2.40 

4.00 

5.60 

8.00 

10.40 

11.20 

13.60 

13.60 

16.80 

20.80 

32.80 


The  author's  personal  views  on  the  dietetic  treatment  of  hyper- 
acidity and  hypersecretion  have  been  clearly  stated  in  pages  197  to 
199,  on  the  basis  of  a  very  large  number  of  quantitative  analyses  of 
the  gastric  contents  of  forty-two  normal  healthy  adults.  He  has 
become  convinced  that  proteids,  such  as  beef,  eggs,  fish,  etc.,  cause 
a  stronger  secretion  of  HCl  than  amylaceous  foods,  such  as  rice, 
sago,  farina,  cerealin.  When  the  glandular  layer  is  in  a  state  of  in- 
creased excitation  it  is  logical  to  avoid  proteid  and  albuminous 
food  as  much  as  possible.  We  have  made  numerous  prolonged 
observations  showing  that  amylaceous  foods  and  fats  can  maintain 
the  nitrogen  equilibrium,  and  even  add  to  body- weight  when  proteids 
are  excluded.  We  do  not  wish  to  defend  the  standpoint  of  the 
vegetarian,  as  we  generally  allow  a  small  quantity  of  easily  digest- 
ible meat  for  dinner,  and  advise  about  i^  liters  of  milk  if  it  agrees 
well.  The  views  of  v.  Sohlern  on  this  question  merit  careful  inves- 
tigation. 


FATTENING   CURE   FOR   NEUROSES. 


251 


SCHEDULE  FOR  INTESTINAL  ANTISEPSIS  BY  MILK  DIET. 
Also  Available  in  Neurasthenia,  Sensory  and   Secretory  Neuroses.— 

i^Biirkart.) 

First  Day  : 

7.30  A.M. — One-half  of  a  liter  of  milk  and  two  pieces  of  toast  (the  milk  is  to  be 

taken  a  mouthful  or  a  spoonful  at  a  time,  yi  o{  2,  liter  in  one-half  hour). 
10  a.  m. — One-third  of  a  liter  of  milk  and  one  toast. 
12.30  P.  M. — One  plate  of  soup  with  one  egg,  50  gm.  of  roast  meat.     Potato 

puree. 
3.30  P.  M. — One-third  of  a  liter  of  milk  and  one  toast. 
5.30  p.  M. — One-half  of  a  liter  of  milk  and  two  toasts. 
8  p.  M.— One-half  of  a  liter  of  milk,  50  gm.  of  roast  meat,  wheat  bread  and 

butter. 

On  the  ninth  day  the  following  list  is  applicable : 

7.30  a.  m. — One-half  of  a  liter  of  milk  and  two  toasts. 

8.30  A.  M. — Coffee  and  cream,  wheat  bread  and  butter. 

10  A.  M. — One-third  of  a  liter  of  milk  and  two  toasts. 

12.  M. — One-half  of  a  liter  of  milk. 

I  p.  M. — Soup  with  one  egg,  100  gm.  of  meat,  mashed  potatoes,  75  gm.  of 

stewed  prunes. 
3.30  p.  M. — One-half  of  a  liter  of  milk, 
5.30  p.  M. — One-third  of  a  liter  of  milk  and  two  toasts. 
8  p.  M.— One-half  of    a   liter   of    milk,    60   gm.   of  meat,  wheat  bread  and 

butter. 
g.30  p.  M. — One-third  of  a  liter  of  milk  and  two  toasts. 

On  the  fifteenth  day  Burkart  (in  a  severe  case  of  dyspepsia  on 
hysterical  basis)  reached  the  following  most  ample  diet  list : 


7  A.  M. 

500  gm.  of  milk, 

8  A.  M. 

One  small  cup  of  coffee  or  tea,  with  20  gm.  of 

cream, 

80  gm.  of  cold  meat,        

One  French  roll, 

20  gm.  of  butter, 

ICO  gm.  of  roast  potatoes, 

10  A.  M. 

300  gm.  of  milk, 

12  M. 

300  gm.  of  milk, 

I  V.  M. 

200  gm.  of  soup, 

206  gm.  of  roast  meat, 

200  gm.  of  mashed  potatoes, 

125  gm.  of  prunes, 

200  gm.  of  flour  food, 


17.0 


0.7 
30.8 
4-5 
0-3 
1.8 


2.2 

76.4 

6.2 

0.4 

12.8 


Fat. 


18.2 


5-0 
2.0 

o-S 
16.6 

lO.O 

10.9 
10.9 

3-0 
S-4 
1.7 

2 1'.  2 


Carbo- 
hydrate. 


24.0 

0.7 
29.0 

O.I 

25.0 

14.4 

14.4 

II.4 

42.6 

8-3 

45-0 


252 


KFFE^CTS   OP   COOKING   ON   FOOD. 


Albumin. 


Carbo- 
hydrate. 


3.30  P.M. 

500  gm.  of  milk,  .  ,    . 
5.30  P.M. 

300  gm.  of  milk,  .  .    , 

80  gm.  of  cold  meat, 

One  French  roll,  .  .    , 

20  gm.  of  butter,  .    . 

8  p.  M. 

80  gm.  of  roast  meat, 

40  gm.  of  toast,  .  .    . 

500  gm.  of  milk,  .  .    . 
9.30  p.  M. 

500  gm.  of  milk,  .  .    . 

20  gm.  of  toast,  .  .    . 


Total, 


Calories,  about 


17.0 

10.2 

30.8 
4-5 
0.3 

30.8 

0.6 

17.0 

17.0 
0.3 


295.0 


10.9 
2.0 

o-S 
16.6 


5-2 
18.2 


18.2 
2.6 


199.8 


1850 


24.0 
14.4 

29.0 
0.1 


33-2 
24.0 

24.0 
16.6 


380.2 


1550 


Total  combustion  value  about  4600  calories. 


Effect  of  Cooking  on  Food. — The  practice  of  cooking  is  not 
equally  necessary  in  regard  to  all  articles  of  food.  There  are  im- 
portant differences  in  this  respect,  and  it  is  interesting  to  note  how 
correctly  the  experience  of  mankind  has  guided  them  in  this  matter. 
The  articles  of  food  which  we  still  use  in  the  uncooked  state  are 
comparatively  few;  and  it  is  not  difficult  in  each  case  to  indicate 
the  reason  of  the  exemption.  Fruits  which  we  consume  largely 
in  the  raw  state  owe  their  dietetic  value  chiefly  to  the  sugar  which 
they  contain;  but  sugar  is  not  altered  by  cooking.  Salads  may  be 
regarded  more  as  a  relish  for  other  food,  and  as  having  a  quasi-medic- 
inal purpose,  rather  than  as  a  substantial  source  of  nutriment.  Milk 
is  consumed  by  us,  both  cooked  and  uncooked,  indifferently,  and 
experience  justifies  this  indifference;  for  Sir  William  Roberts  found, 
on  trial,  that  the  digestion  of  milk  by  pancreatic  extract  was  not 
appreciably  hastened  by  previously  boiling  the  milk.  In  the  author's 
experiments  boiled  milk  was  digested  slower  than  unboiled  milk 
by  pancreatic  juice  of  the  dog. 

This  eminent  writer  characterizes  our  practice  in  regard  to  the 
oyster  as  being  exceptional  and  furnishing  a  striking  example  of 
the  general  correctness  of  the  popular  judgment  on  dietetic  ques- 
tions. The  oyster  is  almost  the  only  animal  substance  which  we 
habitually,  and  by  preference,  eat  in  the  raw  or  uncooked  state; 
and  it  is  interesting  to  know  that  there  is  a  sound  physiological 


CHEMICAIv   CHANGES    PRODUCED    BV    COOKING.  253 

reason  at  the  bottom  of  this  preference.  The  fawn-colored  mass 
which  constitutes  the  dainty  of  the  03^ster  is  its  Hver,  and  this  is 
little  else  than  a  heap  of  glycogen,  or  animal  starch.  Associated 
with  the  glycogen,  but  withheld  from  actual  contact  with  it  during 
life,  is  its  appropriate  digestive  ferment — the  hepatic  diastase.  The 
mere  crushing  of  the  dainty  between  the  teeth  brings  these  two 
bodies  together,  and  the  glycogen  is  at  once  digested,  without  other 
help,  by  its  own  diastase.  The  oyster  in  the  uncooked  state,  or 
merely  warmed,  is,  in  fact,  self -digestive.  But  the  advantage  of 
this  provision  is  wholly  lost  by  cooking,  for  the  heat  employed 
immediately  destroys  the  associated  ferment,  and  a  cooked  oyster 
has  to  be  digested  like  any  other  food— by  the  consumer's  own 
digestive  powers. 

With  regard,  however,  to  the  staple  articles  of  our  food,  the  prac- 
tice of  cooking  them  beforehand  is  universal.  In  the  case  of  the 
farinaceous  articles  cooking  is  actually  indispensable.  When  men 
under  the  stress  of  circumstances  have  been  compelled  to  subsist 
on  the  uncooked  grain  of  the  cereals,  they  have  soon  fallen  into  a 
state  of  inanition  and  disease.  By  the  process  of  cooking,  the 
starch  of  the  grain  is  not  only  liberated  from  its  protecting  enve- 
lopes, but  it  undergoes  a  chemical  change  by  which  it  is  transformed 
into  the  gelatinous  condition,  which  facilitates  the  action  of  the 
diastatic  ferments.  A  change  of  equal  importance  seems  to  be  in- 
duced in  the  proteid  matter  of  the  grain.  Sir  William  Roberts 
found  that  the  gluten  of  wheat  was  much  more  digestible  by  both 
artificial  gastric  juice  and  by  pancreatic  extract  in  the  cooked  than 
in  the  uncooked  state.  In  regard  to  meat  the  advantage  of  cooking 
consists  chiefly  in  its  effects  on  the  connective  tissue  and  the  ten- 
dinous and  aponeurotic  structures  associated  with  muscular  fiber. 
These  are  not  merely  softened  and  disintegrated  by  cooking,  but  are 
chemically  converted  into  the  soluble  and  easily  digested  form  of 
gelatin.  Sir  William  Roberts  made  instructive  observations  on  the 
effects  of  cooking  on  the  contents  of  the  egg.  The  change  induced 
on  egg-albumen  by  cooking  is  very  striking.  For  the  purpose  of 
testing  this  point  he  employed  a  solution  of  egg-albumen  made  by 
mixing  white-of -egg  with  nine  times  its  volume  of  water.  This  solu- 
tion, when  heated  in  the  water-bath,  does  not  coagulate  nor  sensibly 
change  its  appearance,  but  its  behavior  with  the  digestive  ferments 
is  completely  altered.  In  the  raw  state  this  solution  is  attacked 
very  slowly  by  pepsin  and  acid,  and  pancreatic  extract  has  almost 


2  54  THE    PALATE   A    SKILFUIv    GUIDE. 

no  effect  on  it ;  but  after  being  cooked  in  the  water-bath  the  albumin 
is  rapidly  and  entirely  digested  by  artificial  gastric  juice,  and  a 
moiety  of  it  is  rapidly  digested  by  pancreatic  extract.* 

Indications  of  the  Palate.— Sir  William  Roberts  ("Digestion 
and  Diet")  holds  that  "the  indications  of  the  palate  are  of  great 
importance  in  the  regulation  of  diet,  and  should  always  be  inquired 
into  and  carefully  considered.  The  palate  is  placed  like  a  dietetic 
conscience  at  the  entrance  gate  of  food,  and  its  appointed  function 
is  to  pass  summary  judgment  on  the  wholesomeness  or  unwhole- 
someness  of  the  articles  presented  to  it.  It  acts  under  the  influence 
of  a  natural  instinct,  which  is  rarely  at  fault.  This  instinct  repre- 
sents an  immense  accumulation  of  experience,  partly  acquired  and 
partly  inherited.  It  is,  of  course,  not  infallible — no  instinct  is;  but 
so  close  and  true  are  the  sympathies  of  the  palate  with  the  stomach 
and  the  rest  of  the  organism  that  its  dictates  are  entitled  to  the 
utmost  deference  as  those  of  the  rightful  authority  in  the  choice  of 
food.  I  am,  of  course,  aware  that  the  palate — or,  rather,  the  civilized 
palate — is  not  always  credited  with  these  solid,  good  qualities. 
Some  persons  there  are,  not  medical  authorities,  who  distrust  its 
office  and  regard  its  indications  with  suspicion,  as  if  they  were  the 
suggestions  of  some  frivolous  and  wanton  agency,  tempting  men  to 
a  vain  gratification  of  the  senses,  rather  than  as  those  of  an  honest 
and  skilful  guide  in  the  choice  of  food.  This  puritanical  view  of 
the  palate  is  wholly  unscientific ;  it  moreover  implies,  to  speak  figura- 
tively, a  gross  slander  on  a  responsible  and  rarely  endowed  organ, 
which  has  performed  in  the  past,  and  still  performs,  most  difficult 
and  most  complicated  functions  with  conspicuous  success;  for  who 
shall  venture  to  say  that,  in  the  evolution  of  the  human  animal  from 
the  short-lived,  immoral,  and  stupid  savage,  with  his  diet  of  wild 
fruit,  roots,  raw  flesh,  and  unfiltered  water,  to  the  status  of  civilized 
man,  the  promptings  of  the  palate  have  not  played  an  important 
and  even  indispensable  part?  We  are  apt  to  forget  that  there  is  no 
such  a  thing  as  an  absolutely  good  or  an  absolutely  bad  flavor  to 
the  animal  palate.  Sweet  things  are  indift'erent  to  the  palate  of  the 
camivora ;  and,  conversely,  the  taste  of  flesh  has  no  attraction  to  the 
herbivora.  Each  animal  has  its  own  gustatory  standard,  which  is 
accurately  adjusted  to  the  wants  of  its  particular  economy." 


*  Raw  egg-albumin  does  not  require  digestion  and  can  be  absorbed  from  the  intestine 
as  such  ;  in  the  stomach  it  invariably  undergoes  digestion  by  pepsin  hydrochloric  acid. 


DIETETICAL    COOKING.  255 

DIETETICAL  COOKING* 

General  Remarks. — It  is  evident  that  the  subtle  art  of  cooking 
can  be  practised  with  advantage  to  those  suffering  from  indigestion 
only  by  those  who  understand  thoroughly  the  general  fundamental 
principles  of  the  art,  and  have  in  addition  some  experience  therein. 
But  if  diligence,  care,  and  cleanliness  are  very  desirable  qualities 
in  cooking  for  people  in  good  health,  they  become  an  absolute  neces- 
sity for  those  who  undertake  the  preparation  of  food  for  digestive 
organs  whose  functions  are  impaired.  By  no  means  should  the 
attention  be  taken  from  the  work  by  other  matters,  for  in  that  case 
the  care  which  is  necessary  will  suffer,  and  the  most  scrupulous 
cleanliness  must  be  applied  (Wegele). 

It  should  be  understood  here  that  we  have  confined  ourselves  to 
the  most  necessary  things,  and  have  not  considered  the  details  con- 
cerning the  arrangement  of  the  kitchen,  construction  of  the  fire- 
place, the  cooking  utensils  and  fuel,  food-stuffs  or  their  adulteration; 
and,  further,  we  have  not  undertaken  the  description  of  complicated 
dishes,  but  have  given  directions  for  the  preparation  of  only  the 
simplest  every-day  dishes  in  such  a  way  as  to  serve  dietetical  pur- 
poses. In  this  respect  the  advice  of  Penzoldt  deserves  considera- 
tion, to  use  vessels  with  protecting  lids  for  the  keeping  of  foods 
which  are  to  be  eaten  later  when  cold.  Naturally  all  food-stuffs 
must  be  of  the  best  quality,  for  the  best  is  just  good  enough  for  the 
sick.  Aside  from  this,  nothing  in  the  sHghtest  degree  spoiled  may 
be  used  in  cooking  for  the  sick.  In  the  eulogy  of  the  palate  we 
have  already  emphasized  appetizing  preparation,  for,  as  is  well 
known,  dyspeptics  are  easily  seized  by  nausea,  while,  on  the  other 
hand,  a  suitable  way  of  preparing  food  may  stimulate  the  appetite. 
For  the  same  reason,  every  after-taste  due  to  the  character  of  the 
cooking  utensils  or  their  uncleanliness  is  to  be  avoided  as  far  as 
possible,  and  the  utensils  should  be,  wherever  possible,  earthen, 
enameled,  or  nickel-plated.  Food  must  never  be  brought  to  the 
table  too  hot,  for  the  patients  are  thus  tempted  to  eat  them  in  this 
state  in  spite  of  the  directions  of  the  physician,  and  on  this  account 

*  We  have  availed  ourselves  of  a  large  number  of  works  in  compiling  this  particular 
chapter.  The  name  of  the  originator  of  any  particular  article  of  diet  has  been  added  to 
the  directions  given  whenever  it  was  obtainable.  Of  the  larger  works  used  we  mention 
Sir  William  Roberts,  Munk  and  Uffelmann  (last  edition  by  C.  A.  Ewald),  Wegele, 
Biedert  and  Langermann,  Leyden's  "  Handbuch  der  Ernahrungstherapie,"  Oilman 
Thompson,  Boas,  Penzoldt  and  Stintzing's  "  Handbuch  der  Therapie,"  etc. 


256  GENERAL    DIRECTIONS    REGARDING    COOKING. 

it  is  best  to  put  the  food  on  a  second  plate  or  cup.  The  contrary 
is  just  as  injurious,  and  it  therefore  is  well  to  prepare  foods,  which 
are  subject  to  rapid  cooling,  in  vessels  with  double  bottoms,  filled 
with  hot  water.  Concerning  the  seasoning  of  the  dishes,  only  a 
moderate  use  of  cooking  salt  is  allowed,  and  other  spices  are  not  to 
be  used  without  the  permission  of  the  physician;  Wegele  strictly 
forbids  the  use  of  citron  or  pomegranate  skins  in  dietetical  cooking. 
Water  which  is  to  be  used  for  cool  drinks  should  be  boiled  and  then 
allowed  to  cool. 

Concerning  the  measures  used  in  the  following  chapter, — 

I  teaspoon  equals  about  5  gm-j 
I  tablespoon  equals  about  15  gm., 
I  soup  plate  equals  about  250  gm., 
I  cup  equals  about  200  to  250  gm., 
I  wineglass  equals  about  150  gm., 

in  which  calculation  naturally  no  attention  has  been  paid  to  the 
specific  gravity  of  the  different  substances. 

I.  Drinks  and  Liquid  Foods. 

Barley  Soup  {Ringer). — To  a  tablespoonful  of  pearl  barle}"  washed 
in  cold  water  add  two  or  three  lumps  of  sugar,  the  rind  of  one  lemon, 
and  the  juice  of  half  a  lemon.  On  these  pour  a  quart  of  boiling 
water,  and  let  the  mixture  stand  for  seven  or  eight  hours.  Strain. 
The  barley  water  should  never  be  used  a  second  time.  Half  an  ounce 
of  isinglass  ma}'  be  boiled  in  the  water.  If  not  needed  at  once, 
these  barley  preparations  should  be  kept  in  the  refrigerator,  and 
warmed  when  required.     They  are  unpalatable  if  taken  cold. 

Rice-water,  or  Mucilage  of  Rice  (Pavy). — Thoroughly  wash 
one  ounce  of  rice  with  cold  water.  Then  macerate  for  three  hours 
in  a  quart  of  water  kept  at  a  tepid  heat,  and  afterward  boil  slowly 
for  an  hour,  and  strain.  A  useful  drink  in  dysentery,  diarrhea,  and 
irritable  states  of  the  alimentary  canal.  It  may  be  sweetened  and 
flavored  in  the  same  way  as  barley  water. 

Lemonade  (Pavy). — Pare  the  rind  from  a  lemon  thinly,  and  cut 
the  lemon  into  slices.  Put  the  peel  and  sliced  lemon  into  a  pitcher 
with  one  ounce  of  white  sugar,  and  pour  over  them  one  pint  of  boiling 
water.  Cover  the  pitcher  closely,  and  digest  until  cold.  Strain  or 
pour  off  the  liquid. 

Beef-essence  (Yeo). — Cut  the  lean  of  beef  into  small  pieces  and 
place  them  in  a  wide-mouthed  bottle  securely  corked,   and  then 


DRINKS    AND    LIQUID   FOODS.  257 

allow  it  to  stand  for  several  hours  in  a  vessel  of  boiling  water.  This 
may  be  given  in  teaspoonful  doses  to  infants  who  can  not  take  milk, 
and  in  larger  quantities  to  adults. 

Beef-tea  (Gerviain  See). — Meat  cut  into  small  pieces,  cold  water 
added,  and  then  gradually  heated  to  140°  or  160°  F.  Press,  strain, 
and  flavor  with  salt  and  pepper.  This  is  much  inferior  to  the  prepara- 
tions made  with  hydrochloric  acid. 

Chicken  Broth  (Bartholomew). — Skin  and  finely  mince  a  small 
chicken  or  half  of  a  large  fowl,  and  boil  it,  bones  and  all,  with  a 
blade  of  mace,  a  sprig  of  parsley,  and  a  crust  of  bread,  in  a  quart 
of  water  for  an  hour,  skimming  it  from  time  to  time.  Strain  through 
a  coarse  colander. 

Chicken,  Veal,  or  Mutton  Broth  (Yeo). — Chicken,  veal,  or 
mutton  broth  may  be  made  like  beef -tea,  substituting  chicken,  veal, 
or  mutton  for  beef,  boiling  in  a  saucepan  for  two  hours,  and  straining. 
For  chicken  broth  the  bones  should  be  crushed  and  added.  For 
veal  broth  the  fleshy  part  of  the  knuckles  should  be  used.  Either 
may  be  thickened  and  their  nutritive  value  increased  by  the  addition 
of  pearl  barley,  rice,  vermicelli,  or  semolina. 

Mutton  and  Chicken  Broths  (Osier). — Mince  a  pound  of  either 
chicken  or  mutton,  freed  from  fat,  put  into  a  pint  of  cold  water,  and 
let  stand  in  a  cold  jar  on  ice  two  or  three  hours.  Then  cook  for 
three  hours  over  a  slow  fire,  strain,  cool,  skim  off  fat,  add  salt,  and 
serve  hot  or  cold.  Such  broth  is  much  better  than  any  manufac- 
tured meat  preparations.  Good  mutton  broth  is  difficult  to  make 
on  account  of  the  meat  containing  so  much  fat. 

Raw  Meat  Diet  (Ringer). — Use  two  ounces  of  rump  steak;  take 
away  all  fat,  cut  into  small  squares  without  entirely  separating  the 
meat,  place  in  a  mortar,  and  pound  for  five  or  ten  minutes ;  then  add 
three  or  four  tablespoonfuls  of  water  and  pound  again  for  a  short 
time,  afterward  removing  all  sinews  or  fiber;  add  salt  to  taste.  Before 
using,  place  the  cup  or  jar  containing  the  pounded  meat  in  hot  water 
until  just  warm. 

Or  scrape  the  beefsteak  with  a  sharp  knife,  and  after  removing  all 
fat  and  tendon,  if  not  already  in  a  complete  pulp,  pound  in  a  mortar. 
Flavor  with  salt  and  pepper.  This  may  be  taken  in  the  form  of  a  sand- 
wich, between  thin  bread  and  butter,  or  mixed  with  water  to  the  con- 
sistency of  a  cream.  If  preferred,  the  meat  may  be  rolled  into  balls 
with  a  little  white-of-egg,  and  boiled  for  two  or  three  minutes,  or  until 
the  outside  turns  gray,  just  long  enough  to  remove  the  raw  taste. 


258  DRINKS   AND   LIQUID   FOODS. 

Chicken  Jelly  (Adams). — Clean  a  fowl  that  is  about  a  year  old, 
remove  skin  and  fat;  chop  fine,  bones  and  flesh,  in  a  pan  with  two 
quarts  of  water;  heat  slowly,  skim  thoroughly,  simmer  five  to  six 
hours ;  add  salt,  mace,  or  parsley  to  taste ;  strain ;  cool.  When  cool, 
skim  off  the  fat. 

The  jelly  is  usually  relished  cold,  but  may  be  heated.  Give  often 
in  small  quantities. 

Milk-punch. — Make  by  adding  brandy  or  whiskey  or  rum  to  milk 
in  the  proportion  of  about  one  to  four  or  six  parts  of  milk;  flavor 
with  sugar  and  nutmeg;  shake  well. 

Sherry  or  Brandy  and  Milk  (Ringer). — To  one  tablespoonful  of 
brandy  or  one  wineglassful  of  sherry,  in  a  bowl  or  cup,  add  powdered 
sugar  and  a  very  little  nutmeg  to  taste.  Warm  a  breakfast  cupful 
of  new  milk  and  pour  into  a  pitcher.  Pour  the  contents  from  a 
height  over  the  wine,  sugar,  etc.     The  milk  must  not  boil. 

Junket  (Anderson). — Sweeten  with  white  sugar  one  pint  of  good 
milk.  If  wine  is  allowed,  a  dessertspoonful  of  sherry  is  an  improve- 
ment. Heat  to  new-milk  warmth,  pour  into  a  shallow  dish,  and 
stir  in  two  teaspoonfuls  of  essence  of  rennet.  This  will  form  a  slight 
curd.  Grate  a  little  nutmeg  over  it,  or  add  a  pinch  of  powdered 
cinnamon.  Serve  when  quite  cold.  In  cold  weather  the  milk  should 
be  placed  in  a  warm  room  to  set.  An  excellent  food  and  good  sub- 
stitute for  milk  in  typhoid  fever,  etc. 

Egg-nog, — Egg-nog  is  made  by  adding  the  beaten  yolk  of  egg  and 
a  little  spirits  to  a  tumblerful  of  milk,  stirring  well,  adding  sugar  and 
white  of  the  egg,  separately  beaten.  The  digestibility  of  both  of  these 
highly  nourishing  and  stimulating  preparations  is  enhanced  by  the 
addition  of  ^  of  an  ounce  of  lime-water,  which  does  not  affect  the  taste. 

Egg  and  Wine  (Ringer). — Take  one  &gg,  ^  of  a  glass  of  cold 
water,  one  glass  of  sherry,  sugar,  and  a  very  little  nutmeg,  grated. 
Beat  the  egg  to  a  froth  with  a  tablespoonful  of  cold  water.  Make 
the  wine  and  water  hot,  but  not  boiling ;  pour  on  the  egg,  stirring  all 
the  time.  Add  sufiicient  sugar  to  sweeten,  and  a  very  little  nutmeg. 
Put  all  into  a  porcelain-lined  saucepan  over  a  gentle  fire,  and  stir 
one  way  till  it  thickens,  but  do  not  let  it  boil.  Serve  in  a  glass,  with 
crisp  biscuits  or  sippets  of  toast. 

Milk  for  Pudding  or  Stewed  Fruit  (Ringer). — Boil  a  strip  of 
lemon  and  two  cloves  in  a  pint  of  milk;  mix  ^  of  a  teaspoonful  of 
arrowroot  in  a  little  cold  milk  and  add  it  to  the  boiling  milk;  stir  it 
until  about  the  consistency  of  cream.     Have  readv  the  volks  of 


DIETETIC    FOODS   AND    DRINKS.  259 

three  eggs  beaten  up  well  in  a  little  milk.  Take  the  hot  milk  off  the 
fire,  and  as  it  cools  add  the  eggs  and  a  teaspoonful  of  orange-flour 
water,  stirring  it  constantly  till  quite  cool.  Keep  it  in  a  very  cool 
place  until  required  for  use. 

Arrowroot  Blancmange  {Ringer). — Take  two  tablespoonfuls  of 
arrowroot,  f  of  a  pint  of  milk,  lemon,  and  sugar  to  taste. 

Mix  the  arrowroot  with  a  little  milk  to  a  smooth  batter;  put  the 
rest  of  the  milk  on  the  fire  and  let  it  boil,  sweeten  and  flavor  it, 
stirring  all  the  time  till  it  thickens  sufficiently.  Put  into  a  mold 
until  quite  cold. 

Arrowroot  (Pavy). — Mix  thoroughly  two  teaspoonfuls  of  arrow- 
root with  three  tablespoonfuls  of  cold  water,  and  pour  on  them  ^ 
of  a  pint  of  boiling  water,  stirring  well  meanwhile.  If  the  water 
is  quite  boiling,  the  arrowroot  thickens  as  it  is  poured  on,  and  nothing 
more  is  necessary.  If  only  warm  water  is  used,  the  arrowroot  must 
be  boiled  afterward  until  it  thickens.  Sweeten  with  loaf-sugar,  and 
flavor  with  lemon-peel  or  nutmeg,  or  add  sherry,  port- wine,  or  brandy 
if  required.  Boiling  milk  may  be  employed  instead  of  water,  and  when 
this  is  done  no  wine  must  be  added,  as  it  would  otherwise  curdle. 

Oatmeal  Gruel  (Plain). — Two  tablespoonfuls  of  oatmeal,  one 
saltspoonful  of  salt,  one  scant  teaspoonful  of  sugar,  one  cup  of  boiling 
water.  Cook  for  thirty  minutes;  then  strain  through  a  fine  wire 
strainer  to  remove  the  hulls,  place  again  on  the  stove,  add  the  milk, 
and  heat  just  to  the  boiling  point.     Serve  hot. 

Farina  Pudding  (U.  S.  Army  Hospital  Recipe  for  12  Men). 
— Farina,  ^  of  a  pound;  milk,  two  pints;  water,  one  pint;  sugar, 
2^  ounces;  eggs,  four  ounces;  nutmeg,  ^  of  an  ounce. 

Directions. — Put  the  water  into  a  stewpan  with  a  little  salt.  When 
it  boils  stir  in  the  farina.  Let  it  boil  twenty  minutes.  Stir  in  the 
milk,  which  must  be  hot.  Beat  the  eggs  until  they  are  very  light; 
mix  the  sugar  with  them.  Stir  in  the  eggs  and  sugar  with  the  farina. 
Add  the  spice.  Put  it  into  a  moderate  oven  and  bake  a  half  or  three- 
quarters  of  an  hour. 

Port-wine  Jelly  (Ringer). — Put  into  a  jar  one  pint  of  port-wine, 
two  ounces  of  gum  arable,  two  ounces  of  isinglass,  two  ounces  of 
powdered  white  sugar-candy,  I-  of  a  nutmeg  grated  fine,  and  a  small 
piece  of  cinnamon.  Let  this  stand  closely  covered  all  night.  The 
next  day  put  the  jar  into  boiling  water  and  let  it  simmer  until  the 
contents  are  dissolved;  then  strain,  let  stand  till  cold,  and  then  cut 
into  small  pieces  for  use. 


26o  DIKT  IvISTS. 

Nutritious  Coffee  {Ringer). — Dissolve  a  little  isinglass  in  water, 
and  then  put  ^  of  an  ounce  of  freshly  ground  coffee  into  a  sauce- 
pan with  one  pint  of  new  milk,  which  should  be  nearly  boiling  before 
the  coffee  is  added;  boil  both  together  for  three  minutes.  Clear 
it  by  pouring  some  of  it  into  a  cup  and  dashing  it  back  again,  add 
the  isinglass,  and  let  it  settle  on  the  hob  for  a  few  minutes.  Beat 
upon  egg  in  a  breakfast  cup  and  pour  the  coffee  upon  it ;  if  preferred, 
drink  it  without  the  &gg. 

Glair-water. — Into  200  c.c.  of  cold  water  which  has  previously 
been  boiled,  put  with  constant  stirring  the  white  of  one  &gg,  and 
add,  according  to  prescription,  three  teaspoonfuls  of  powdered  sugar, 
or  grape-sugar,  or  10  gm.  of  cognac.  The  white  of  an  e.gg  equals 
about  12  calories;  15  gm.  of  sugar  equals  about  50  calories;  10  gm. 
of  cognac  equals  50  calories. 

Kefyr. — It  is  best  to  procure  moist  kefyr  mushrooms  (not  the 
dried  grains)  prepared  for  immediate  use.  They  can  be  procured 
from  the  Caucasian  Kefyranstalt  in  Breslau,  or  from  Dr.  M.  Lehmann, 
Berlin  C.  (43  and  44  Heiligegeist  Strasse).  Pour  away  the  liquid 
contained  in  the  bottle,  wash  the  mushrooms  in  a  lukewarm  (about 
15°  R.  or  18.7°  C.)  soda  solution  of  5  :  1000,  rinse  with  clear  luke- 
warm water,  and  after  pouring  off  the  water  place  the  mushrooms 
in  a  vessel  of  porcelain  or  Bunglan  clay  of  two  liters'  capacity.  Pre- 
viously two  liters  of  milk  should  have  been  boiled  and  allowed  to 
cool  again.  Now  pour  the  milk,  whose  temperature  should  be  about 
15°  R.  or  18.7°  C,  upon  the  mushrooms,  close  the  vessel  tightly, 
and  let  it  stand  twenty-four  hours  in  a  place  whose  temperature  is 
13°  to  15°  R.  or  18.7°  C.  (in  summer  in  the  cellar),  during  which  time 
it  is  expedient  to  often  stir  the  milk  carefully.  At  the  expiration 
of  this  time  it  should  be  stirred  again,  and  the  milk  is  then  poured 
through  a  moderately  fine  wire  sieve  into  thoroughly  cleaned  bottles 
with  patent  stoppers.  These  bottles  are  again  to  be  kept  twenty- 
four,  thirty-six,  forty-eight,  or,  at  the  highest,  fifty-four  hours  (accord- 
ing as  kefyr  one,  two,  three,  or  four  days  old  has  been  prescribed)  in 
a  place  whose  temperature  is  kept  at  about  15°  R.  or  18.7°  C,  lying, 
not  standing  up,  and  are  then  ready  for  use. 

The  process  of  fermentation  may  be  hastened  by  frequent  shak- 
ing, also  with  heat,  on  which  account  the  fermentation  takes  place 
more  quickly  in  midsummer,  and  the  kefyr  consequently  will  be 
finished  sooner.  The  mushrooms  which  remained  in  the  sieves  after 
pouring  off  the  milk  into  the  patent  flasks  must  each  time  be  rinsed 


MEAT  EXTRACTS,    ETC.  261 

with  lukewarm  water  and  freed  from  particles  of  cheese,  and  after- 
ward placed  again  in  the  thoroughly  clean  porcelain  vessel,  and  milk 
is  then  again  poured  upon  them.  After  two  or  three  days  the  prepara- 
tion is  so  regulated  that  each  day  two  bottles  (of  one  liter  each) 
become  ready  for  use,  for  which  reason  four  patent-stoppered  bottles 
are  necessary.  Once  a  week  the  bottles  must  be  rinsed  with  a  luke- 
warm soda  solution  of  5  :  1000  instead  of  with  lukewarm  water, 
in  order  to  free  them  from  acid.  At  first  let  the  patient  drink  one 
wineglassful  two  or  three  times  a  day,  then  |  of  a  liter,  and  con- 
stantly increase  the  quantity  until  the  prescribed  dose  has  been 
reached.     One  hundred  gm.  of  kefyr  equal  about  45  calories. 

Almond  Milk. — Thirty  grs.  of  sweet  almonds  and  two  bitter 
almonds  are  blanched  after  they  have  lain  twenty-four  hours  in 
cold  water.  One  can  also  scald  the  almonds  with  boiling  water; 
then  they  can  be  easily  pressed  out  of  their  hulls  after  a  few  minutes. 
The  almonds  are  either  ground  in  a  mill  or  pounded  in  a  mortar, 
then  mixed  with  ^  of  a  liter  of  warm  water  or  warm  milk,  and  the 
mixture  is  allowed  to  stand  two  hours,  after  which  it  is  strained 
through  a  cloth  and  the  juice  well  pressed  out. 

Thirty  grs.  of  almonds  equal  200  calories;  250  gm.  of  milk  equal 
170  calories. 

Extract  of  Meat  {according  to  Wiel),  "Succus  carnis  recenter 
expressus." — Meat  free  from  fat  is  chopped  fine,  arranged  in  several 
layers,  which  are  separated  by  coarse  (filter)  linen,  and  subjected 
to  pressure  in  a  colander;  the  juice  is  given  pure  (as  medicine)  by 
the  teaspoonful,  or  also  diluted  with  beef-tea,  but  must  not  be  sub- 
jected to  a  temperature  higher  than  50°  R.  or  62.5°  C,  for  otherwise 
the  albuminous  parts  contained  in  it  would  coagulate.  "Valentine's 
meat-juice"  (extract)  may  serve  as  a  good  substitute  for  the  fresh 
extract  of  meat  particularly  prepared.  A  teaspoonful  of  this  pre- 
paration is  diluted  with  one  to  two  tablespoonfuls  of  cold,  or, 
at  the  most,  lukewarm,  water;  the  yolk  of  one  egg  may  also  be 
added. 

Meat-extract  Ice  {according  to  v.  Ziemssen) . — One  k.  of  fresh  beef 
is  cut  into  pieces  the  size  of  a  hand,  and  is  wrapped  in  coarse  lattice- 
like linen,  put  under  a  lever-press  and  slowly  pressed;  this  is  best 
done  by  an  apothecary.  The  juice  is  caught  in  a  porcelain  dish. 
In  this  way  one  gets  about  500  gm.  This  is  mixed  with  250  gm. 
of  sugar  and  20  gm.  of  freshly  pressed  lemon-juice  (though  this  had 
better  be  omitted  for  dyspeptics),  and  20  gm.  of  cognac,  containing 


262  DIET   I.ISTS. 

extract  of  vanilla,  which  has  been  well  stirred  with  the  yolks  of  three 
eggs,  are  added,  and  the  whole  is  placed  in  a  freezer. 

Bottled  Bouillon  {according  to  Uffelmann).- — Three  hundred  gm. 
of  fresh,  lean  meat  are  cut  into  small  blocks  and,  without  any  ad- 
dition, are  put  into  a  clean  bottle  with  wide  mouth.  This  is  closed, 
if  there  be  no  suitable  stopper,  with  a  stopper  of  pure,  sterilized 
cotton,  and  placed  in  a  vessel  of  warm  water,  slowly  heated,  and 
the  water  should  be  allowed  to  boil  one-half  hour.  The  bottle, 
which  is  now  to  be  taken  out,  contains  about  loo  gm.  of  a  turbid, 
brown  broth,  which  is  poured  off  without  straining. 

Simple  Bouillon,  or  Beef-tea. — One-half  of  a  k.  of  lean  beef  is 
cut  into  small  pieces,  put  into  a  pot  holding  about  three  liters,  with 
a  well-fitting  cover,  or  into  a  steam  cooking  apparatus.  This  is  to 
be  filled  with  cold  water,  and  the  meat  to  be  boiled  three  to  four 
hours.  According  as  the  bouillon  is  desired  concentrated  or  dilute, 
the  liquid  which  evaporates  must  be  replaced  by  the  addition  of 
boiling  water.  Finally,  one  obtains  about  two  liters  of  bouillon, 
and  the  meat  which  remains  is  of  no  further  use.  To  obtain  greater 
palatability  and  a  prettier  color  the  meat  may  be  first  browned  in  a 
little  hot,  pure  lard  before  cooking,  fresh  soup  herbs  or  a  handful  of 
dried  Knorr's  julienne  added ;  then  finally  add  the  three  liters  of  cold 
water. 

Meat- jelly-  {according  to  Hepp). — Good  beef,  free  from  fat  and 
bones,  is  cooked  on  the  water-bath  with  a  little  water  for  sixteen 
hours,  until  it  congeals  into  jelly.  Often  one  is  compelled  to  use 
artificial  preparations  in  the  making  of  bouillon  or  in  strengthening 
weak  bouillon.  The  most  reliable  in  this  respect  is  Liebig's  extract 
of  meat  (about  ten  c.c.  to  250  gm.),  or  Cibil's  bouillon  (one  table- 
spoonful  to  250  gm.);  very  convenient  also  are  Ouaglio's  bouillon 
capsules.  If  at  the  same  time  one  wishes  to  give  to  the  bouillon  an 
increased  nutritive  value,  one  can  add  one  teaspoonful  of  meat- 
peptone;  or  either  Mosquera  Julia  beef-meal,  Armour's  vigoral,  or 
Valentine's  meat-juice  may  be  used. 

A  preparation  which  is  often  of  service  is  Leube-Rosenthal's  meat 
solution.  One  k.  of  beef  is  chopped  fine,  put  into  a  vessel  with  one 
liter  of  water  and  twenty  gm.  of  pure  hydrochloric  acid,  which  vessel 
is  put  in  a  Papin  steam  cooking  apparatus,  in  which  it  should  boil 
ten  to  fifteen  hours  (with  frequent  stirring).  After  this  the  mass  is 
put  into  a  mortar  and  ground  to  an  emulsion.  After  a  further  cook- 
ing of  fifteen  hours  with  bicarbonate  of  soda  it  becomes  neutral,  and 


PREPARATION    OF    SOUPS    WITH   FILLERS.  263 

is  then  steamed  to  a  consistency  of  mush,  and  put  into  four  cans, 
which  are  to  be  soldered.  As  the  making  of  this  preparation  re- 
quires much  time  and  particular  care,  it  is  advisable  to  procure  it 
from  one  of  the  following  firms,  who  put  it  upon  the  market  in  cases 
of  I  k.  (enough  for  an  adult  for  one  day) :  Armour  &  Co.,*  Parke, 
Davis  &  Co.,t  Dr.  Mirus'sche  Hofapotheke  (R.  Stutz),J  Huffner's 
Hof-  und  Ratsapotheke  (R.  Wahrburg),J  C.  Reinhardt  (formerly 
Charrier).§ 

Soups  with  Fillers. 

(a)  Soups  with  Fillers  from  the  Cereal  Kingdom. — The  grains  in 
question  (such  as  barley  or  peeled  barley,  oats,  green  corn,,  rice) 
should  be  softened  the  night  before  in  cold  water,  in  which  they  are 
to  remain  until  the  following  forenoon.  Then  the  water  is  poured 
off  and  the  grains  are  put  on  the  fire  with  weak,  cold  bouillon,  where 
they  should  be  kept  boiling  at  least  three  hours ;  one-half  hour  before 
serving,  the  soup  is  strained  through  a  fine  hair  sieve,  and,  after  the 
addition  of  a  little  meat-extract,  is  made  to  boil  again;  salt  is  then 
added  as  required,  and  to  one  plate  of  soup  the  yolk  of  one  egg  may 
be  added.  If  one  is  to  prepare  a  single  plate  of  such  soups,  the  soup 
meals  of  Knorr  in  Heilbronn  are  very  serviceable,  although  they  do 
not  become  gelatinous  like  the  soups  prepared  from  whole  grains, 
and  are  not  so  appetizing.  These  meals  must  be  stirred  with  cold 
bouillon  to  a  thin  liquid  mass,  and  allowed  to  run  into  boiling  beef- 
tea,  which  after  that  must  boil  at  least  one  to  two  hours  longer. 
Twenty  gm.  of  meal  is  calculated  for  one  plate  of  soup.  In  serving, 
one  can  add  also  the  yolk  of  an  egg.  The  nutritive  value  of  these 
soups  may  be  considerably  increased  by  the  addition  of  aleuronat 
flour.  It  is  best  to  take  eight  gm.  of  aleuronat  flour  and  sixteen  gm. 
of  oat-  or  green-corn  meal  for  one  plate  of  soup,  jj  The  aleuronat 
meal  is  mixed  with  cold  water  (or  beef -tea),  and  is  added  to  the  soup 
only  after  the  latter  has  boiled  one-half  hour.  The  meal  swells 
hardly  at  all,  and  for  that  reason  more  of  the  two  flours  is  to  be  taken 
than  is  necessary,  ordinarily,  in  making  of  soup.  Soups  prepared 
with  twenty  gm.  of  oatmeal,  or  leguminose  meal,  barley-meal,  tapioca, 
rice,  etc.,  have  a  combustion  value  of  about  seventy  to  seventy-five 
calories,  which  is  increased  about  sixty  calories  by  the  addition  of 
the  yolk  of  one  egg. 

'•Chicago.         t  Detroit,  Mich.         +  Jena.         ?  Uerlin  VV.,  27  Behren  Stiasse. 
II  Can  be  procured  from  Dr.  llundhausen's  Starkefabril<,  Hamm  in  Westfalen ;  4_J^  k. 
cost  seven  marks,  C.  O.  D. 
18 


264  DIET   LISTS. 

(b)  Tapioca  Soup. — For  this  soup  the  French  tapioca  of  N.  &  J. 
Bloch  in  Paris,  and  Knorr  in  Heilbronn,  had  best  be  used,  which 
can  be  had  in  most  of  the  larger  fancy  groceries  in  packages  of  250 
gm.  For  one  plate  of  soup  a  heaped  teaspoonful  of  these  grains  is 
boiled  for  half  an  hour  with  beef-tea,  which  has  been  boiling  for 
some  time  previous,  and  to  this,  after  a  quarter  of  an  hour,  a  little 
extract  of  meat,  sufficient  to  cover  the  point  of  a  knife,  is  added; 
if  this  be  added  later,  just  before  serving,  the  taste  of  the  extract  is 
easily  distinguished,  which  is  disagreeable  to  many  patients. 

(c)  Sweetbread  Soup. — The  sweetbread  is  soaked  for  one  hour  in 
cold  water,  which  is  during  this  time  often  to  be  renewed ;  then  it  is 
boiled  in  slightly  salted  beef-tea  or  salt  water  (to  which  one  may  add 
one  teaspoonful  of  julienne  for  improving  the  flavor)  for  one  hour. 
After  it  is  cooked  completely  soft  it  is  taken  out  of  the  beef-tea  and 
freed  from  all  skins,  blood-vessels,  etc.  Now  it  can  be  cut  either  in 
pieces  the  size  of  a  walnut,  which  one  lays  on  the  soup-plate  and 
then  pours  over  the  beef -tea,  or  the  sweetbread  can  be  forced  through 
a  fine  sieve ;  beef- tea  is  poured  over  the  mass  and  the  whole  is  again 
put  on  the  fire  until  it  boils,  after  which  the  soup  may  be  served. 
The  latter  proceeding  is  rather  to  be  recommended  in  the  case  of 
dyspeptics.  One  hundred  gm.  of  sweetbread  (raw)  is  equivalent  to 
about  90  calories. 

(d)  Brain  Soup.— A  calf's  brain  is  allowed  to  lie  in  cold  water  for 
one  hour,  in  order  to  draw  out  the  blood  contained  in  it;  then  the 
water  is  poured  off,  the  brain  is  once  more  thoroughly  washed  and 
cooked  in  weakly  salted  beef-tea  or  salt  water,  with  the  addition  of 
one  teaspoonful  of  julienne,  for  one  hour.  Then  immediately  force 
it  through  a  fine  sieve,  dilute  the  mush  with  beef-tea,  and  cook  it 
again.  In  serving,  the  yolk  of  an  egg  may  be  added.  One  hundred 
gm.  of  calf's-brain  equal  140  calories. 

(e)  Soup  Containing  Meat  (according  to  Professor  M.  Rosenthal). — 
Scraped  raw  beefsteak  is  chopped  fine  and  forced  through  a  sieve;, 
the  mass,  soft  as  butter,  is  thoroughly  mixed  with  the  yolk  of  an 
egg,  and  mixed  in  minute  particles  to  a  greater  or  less  degree  with 
boiling  soup. 

(/)  Meat-puree  Soup  (according  to  Hedwig  Heyl). — Twenty  gm.  of 
grated  rolls  are  cooked  for  one-quarter  of  an  hour  with  |  of  a  liter 
of  bouillon.  Stewed  chicken-meat  is  pounded  fine,  passed  through 
a  hair  sieve,  and  25  gm.  of  it  are  stirred  together  with  one  table- 
spoonful  of  cream  or  one  teaspoonful  of  meat-peptone ;  several  spoon- 


PREPARATION   OF   SOUPS   WITH   FILLERS.  265 

fuls  of  soup  are  added,  and  now  beaten  up  with  the  entire  mass,  and 
served  without  further  cooking. 

{g)  Roll  Soup  {according  to  Hedwig  Heyl). — Thirty  gm.  of  grated 
rolls  are  roasted  with  ten  gm.  of  butter,  without  coloring  the  latter; 
f  of  a  liter  of  bouillon  is  poured  over  and  slowly  boiled  for  half  an 
hour.  The  yolk  of  an  egg  is  beaten  up  with  a  tablespoonful  of  sweet 
or  sour  cream,  and  then  put  into  the  soup,  and  the  latter  is  passed 
through  a  sieve  upon  the  previously  warmed  plate  (equal  to  about 
240  calories). 

{h)  Soup  Biscuit. — Forty  gm.  of  butter  are  stirred  for  one-quarter 
of  an  hour,  afterward  mixed  with  two  whole  eggs,  a  little  salt  is 
added,  and  at  last  40  gm.  of  flour.  In  order  to  make  the  mass  rise 
more  easily,  one  can  add  three  gm.  of  baking-powder  (consisting  of 
bicarbonate  of  soda  and  tartaric  acid,  which  can  be  had  in  most 
drug-stores  in  packages  of  30  gm.).  A  long,  square,  sheet-iron  mold 
is  rubbed  with  butter ;  the  mass  is  put  into  it  and  baked  in  the  oven 
with  moderate  heat  for  half  an  hour.  When  the  biscuit  has  cooled 
off  it  is  taken  out,  cut  into  blocks,  and  can  then  be  added  to  the 
various  soups  (such  as  sweetbread,  brain,  or  pea  soup).  The  whole 
mass  corresponds  to  about  630  calories. 

{i)  Noodle  Soup  {Vermicelli  Soup). — The  noodles  (only  the  best 
quality)  must  be  boiled  half  an  hour  in  very  good  bouillon.  A  soup 
of  about  ten  gm.  of  vermicelli  equals  about  50  calories. 

{k)  Butter-dumpling  Soup. — Thirty  gm.  of  butter  is  stirred  one- 
quarter  of  an  hour,  one  whole  egg  and  a  little  salt  being  added ;  stir 
the  satne  and  mix  well  with  the  butter,  and  then  add  30  gm.  of  flour. 
With  a  teaspoon  rather  long  lumps  are  cut  out  of  the  dough  and  put 
into  boiling  beef-tea,  in  which  they  must  boil  twenty  minutes  more 
on  a  fire  not  too  strong.     The  whole  mass  equals  about  420  calories. 

(/)  Green-pea  Soup  {Mashed). — Fresh  green  peas  are  boiled  in  salt 
water  until  thoroughly  soft ;  in  advanced  seasons,  when  .they  are  no 
longer  very  young,  add  ^  of  a  gm.  of  carbonate  of  soda;  canned 
peas  are  also  very  good  at  any  time  for  making  this  soup.  Let  the 
water  run  off  through  a  strainer,  force  the  peas  through  a  fine  sieve, 
mix  with  a  teaspoonful  of  flour  (aleuronat  flour),  pour  beef -tea  over 
the  mass  and  cook  again;  100  gm.  of  peas  equal  75  calories;  ^  of  a 
liter  (420  gm.)  of  peas  gives  280  gm.  of  mashed,  equal  to  300  calories. 

II.  Fish. 

Fish  for  the  table  of  a  sick  person  should  never  be  boiled  or  fried 


266  DIET   USTS. 

in  fat,  but  boiled  only  in  water.  Of  the  fresh-water  fish  the  trout, 
the  perch-pike  (Lucioperca  sandra),  pike,  carp,  gra^ding,  and  salmon 
come  under  consideration  here.  Of  salt-water  fish  the  black  or  sea- 
bass,  sea-trout,  the  bluefish  (Pomatomus  saltator),  the  mackerel,  cod, 
rockfish,  and  haddock  are  suitable.  The  fish  is  carefully  freed  from 
scales,  rubbed  inside  with  salt,  and  boiled  in  very  strongly  salted 
water,  in  which  it  is  allowed  to  remain,  according  to  its  size,  from 
one-quarter  to  one-half  hour.  All  spices  are  to  be  omitted;  only  a 
handful  of  dried  julienne  may  be  put  in  the  boiling  water,  by  which 
the  flavor  is  considerably  increased.  All  fat  and  pungent  sauces  are 
to  be  avoided,  and  even  hot  butter  will  generally  not  agree  with  the 
dyspeptic;  so  that  it  is  best  to  put  only  a  little  fresh  butter  on  the 
fish  when  serving.  Of  the  sea-fish,  the  cod,  rose-fish,  and  haddock 
are  to  be  recommended.  Their  preparation  is  the  same,  except  that 
they  are  soaked  one-quarter  of  an  hour  previously  in  fresh  water 
(not  in  boiling,  but  cold  water),  in  which  is  put  a  large  quantity  of 
salt  and  also  some  julienne.  The  vessel  must  be  large  enough  to 
allow  the  fish  to  be  surrounded  on  all  sides  by  the  water.  A  two-  or 
three-pound  haddock  must  remain  on  the  fire  thirty  to  forty  minutes 
to  be  thoroughly  done ;  sea-fish  also  are  to  be  served  with  fresh  butter. 

III.  Meats. 

I.  Sirloin  {Fillet). — For  the  tenderness  of  beef  it  is  of  importance 
that  it  be  allowed  to  hang  long  enough ;  for  this  two  to  four  da3'S  are 
necessary  in  summer,  in  winter  as  many  as  eight  da5^s;  only  in  the 
coldest  season  must  it  be  protected  from  frost,  through  which  it  be- 
comes very  dry.  The  meat  is  freed  from  all  fat,  the  membranous 
parts,  well  beaten,  washed  and  salted,  and  then  put  into  a  stewpan 
with  hot  lard,  in  which  it  is  quickly  turned  over  several  times.  The 
meat  loses,  in  roasting  in  the  English  style,  ten  per  cent,  in  weight, 
and  in  slow  roasting,  thirty  per.  cent  in  weight.  To  prepare  a  fillet 
in  English  style,  so  that  it  is  still  red  inside,  one  calculates  for  each 
pound  of  meat  one-quarter  of  an  hour;  so  that  a  four-pound  roast 
requires  one  hour's  roasting.  It  is  entirely  unsuitable  to  try,  by 
means  of  sticking  with  a  fork,  how  far  the  roast  is  done,  for  much 
juice  is  lost  by  this,  and  the  cook  must  learn  by  practice,  by  the 
nature  of  the  pan,  the  thickness  of  the  roast,  the  strength  of  the  fire, 
to  calculate  the  period  of  time  necessary  for  the  completion  of  the 
roast.  During  roasting  frequently  add  spoonfuls  of  beef-tea,  so  that 
the  butter  does  not  become  too  dark,  but  the  bouillon  must  never 


PREPARATION   OF   MEATS.  267 

be  poured  upon  the  meat  itself.  One-quarter  of  an  hour  before 
serving,  the  roast  is  taken  out  of  the  pan,  all  fat  is  carefully  skimmed 
from  the  sauce,  a  tablespoonful  of  white  flour  and  a  teaspoonful  of 
aleuronat  flour  are  mixed  with  a  little  cold  bouillon,  a  little  extract 
of  meat  is  added,  and  this  thin  mixture  is  then  added  to  the  sauce 
of  the  roast,  which  is  again  made  to  boil,  and  the  roast  is  again  laid 
into  it  until  serving.  One  hundred  gm.  of  beef  roasted  in  English 
style  equal  about  210  calories. 

2.  Roast  Beef. — This  roast  is  good  and  juicy  only  when  in  large, 
thick  pieces.  The  preparation  is  exactly  the  same  as  the  preceding. 
It  is  juicier  when  roasted  on  the  spit,  though  in  most  households 
the  necessary  equipments  are  wanting.  With  this  meat,  which  has 
a  tolerably  coarse  grain,  a  sufficient  time  for  hanging  is  absolutely 
necessary. 

3.  Raw  Beefsteak  {according  to  Leube). — From  the  loin,  which  has 
hung  a  sufficient  time,  as  much  meat  is  scraped  off  with  a  dull 
spoon-handle  as  can  be  separated  without  violence,  until  one  has  a 
mass  of  about  150  gm.  The  mass  thus  scraped  off  is  slightly  salted, 
made  into  a  very  small  cake,  and  eaten  either  entirely  raw  or  just 
roasted  on  the  surface  in  fresh  butter.  One  hundred  gm.  equal 
about  120  calories. 

4.  Beefsteak  (according  to  Wiel). — Take  some  of  the  best  sirloin 
and  cut  across  a  piece  as  thick  as  a  thumb;  after  this  has  been  well 
pounded  and  slightly  salted  on  one  side,  it  is  put  into  an  iron  or 
enameled  pan,  fried  for  one  minute  on  one  side  in  fresh  butter,  then 
turned,  gravy  poured  over,  and  is  fried  on  the  other  side  only  one- 
half  of  a  minute,  after  which  it  is  immediately  served  on  a  warmed 
plate.     One  hundred  gm.  equal  about  130  calories. 

5.  Beefsteak  in  Oil. — From  a  well-hung  fillet  a  piece  as  thick  as 
a  thumb  is  cut,  all  skins  and  fat  removed,  the  same  well  pounded 
and  salted.  Then  spread  on  both  sides  with  the  finest  olive  oil, 
cover  up  well,  and  allow  it  to  remain  thus  two  hours.  Thereafter 
put  into  the  pan  and  fry  without  any  further  grease  (except  the  oil 
previously  spread  over  it)  till  it  is  brown  on  both  sides.  The  time 
necessary  for  frying  varies  from  five  to  ten  minutes,  according  to 
the  degree  one  wishes  it  done  inside. 

6.  Roast  Veal. — The  leg  of  veal,  after  it  has  hung  a  sufficient 
time,  is  freed  from  the  thick  outside  skin  and  laid  in  sweet  milk  for 
one  or  two  days  in  summer,  two  or  four  days  in  winter,  by  which 
it  becomes  tender  and  soft.     Before  using,  it  is  carefully  washed, 


268  DIET  LISTS. 

thoroughly  skinned,  and  well  salted;  thereupon  it  is  larded  with 
fresh  lard  and  roasted  in  tolerably  hot  butter  or  white  beef-fat,  of 
which  about  200  gm.  are  necessary.  For  the  rest  it  is  treated  like 
any  other  roast,  except  that  it  is  best  (in  the  case  of  veal)  to  roast 
until  well  done,  which  for  a  small  roast  takes  two  hours,  for  a  large 
one  three  hours.  In  the  English  way  one  and  one-quarter  to  two 
hours  are  sufficient.  Roast  veal,  when  the  bone  is  not  previously 
taken  out,  gives  a  very  good,  thick  sauce;  so  that  in  most  cases  it 
is  necessary  to  add  only  a  little  bouillon  after  the  fat  has  been  skimmed 
off.     Its  value  in  calories  is  about  the  same  as  that  of  lean  beef. 

7.  Veal  fricandeau  is  also  laid  in  milk  a  few  days  before  using, 
which  milk  it  is  best  to  let  sour,  for  the  flavor  is  thus  increased;  it 
must  be  done,  however,  in  such  a  manner  that  the  milk  covers  the 
meat  completely.  For  the  rest,  the  meat  is  treated  as  any  other 
veal  roast,  except  that  one  and  a  half  hours'  roasting  with  a  good 
fire  will  suffice.  The  sauce  is  to  be  mixed  with  flour,  and  it  can  be 
given  a  piquant  flavor  by  the  addition  of  some  cream. 

8.  Veal  Cutlets  {Chops). — The  ribs  of  the  calf  are  separated  from 
the  backbone;  the  single  cutlets  separated  from  each  other  are 
washed  and  freed  from  skins,  pounded,  salted,  and  fried  in  a  pan 
with  hot  butter.  They  will  be  more  tender  if  they  have  lain  one 
day  previously  in  milk;  in  this  case  they  need  be  fried  only  eight 
or  ten  minutes,  but  otherwise  it  is  preferable  to  fry  them  from  one- 
half  to  one  hour,  not  leaving  them  long  in  one  place,  often  shoving 
them  to  and  fro,  during  which  time  a  piece  of  fresh  butter  is  also 
added,  and  the  melted  butter  is  constantly  poured  over  the  cutlets. 
Before  serving,  some  good  liquor  from  a  roast  is  added.  To  cover 
cutlets  with  bread-crumbs  is  not  advisable  in  dietetic  cooking.  One 
hundred  gm.  of  fried  veal  cutlets  (also  the  following  veal  dishes) 
equal  230  calories. 

9.  Scotched  Collop. — From  the  leg  of  veal,  which  has  lain  in  milk 
two  or  three  days,  cut  slices  as  thick  as  your  thumb,  wash,  beat  and 
salt  them,  and  put  them  in  a  pan  with  hot  butter,  where  they  must 
be  allowed  to  brown  slightly  on  both  sides.  Then  pour  in  one  glass 
of  white  wine  and  some  bouillon,  cover  up  tightly,  and  let  them 
steam  altogether  for  about  one  and  a  quarter  hours,  pouring  in  some 
bouillon  from  time  to  time.  The  addition  of  sour  cream  improves 
the  flavor;  but  the  digestibility  is  decreased  by  the  sour  cream. 
Then  skim  off  all  fat  and  with  flour  prepare  a  sauce  as  directed  above. 

10.  Fillet  of  Veal. — From  the  fricandeau  piece  cut  strips  one  cm. 


PREPARATION  OF  FOWL,  POULTRY,  ETC.  269 

thick  and  six  cm.  wide,  and  prepare  them  exactly  as  in  No.  9;  in 
the  middle  lay  a  few  pieces  of  middling,  roll  them  up  and  tie  with 
cord.     For  the  rest  proceed  exactly  as  in  the  case  of  scotched  collop. 

11.  Veal  Steak. — Cut  from  the  leg  pieces  as  thick  as  your  thumb, 
weighing  about  100  gm.,  pound  them  well,  wash,  salt  and  lay  them 
in  a  pan  with  hot  butter,  and  fry  them,  with  frequent  turning,  for 
ten  minutes.  Either  add  some  sauce  from  a  roast  or  prepare  one 
from  bouillon,  flour,  and  meat-extract,  which  is  put  into  the  pan, 
and  then  let  the  steaks  fry  in  it  for  two  minutes  longer. 

12.  Lamb's  Saddle. — The  saddle  of  a  young  animal  is  laid  in  milk 
for  two  days,  or  the  milk  is  allowed  to  sour,  through  which  a  venison- 
like flavor  is  obtained.  Before  using,  the  roast  is  washed,  freed 
from  fat  and  skins,  and  larded  with  fresh,  unsmoked  bacon;  then 
it  is  put  into  a  pan  with  previously  heated  beef-fat  or  good  butter, 
in  which  it  must  immediately  be  turned  several  times.  It  is  roasted 
one  and  a  half  hours,  during  which  time  it  is  to  be  diligently  basted 
by  the  addition  of  beef-tea.  In  the  last  hour  pour  in  one  glass  of 
white  wine  and  as  much  bouillon  as  the  sauce  has  boiled  down. 
With  sour  cream  the  roast  becomes  particularly  well  flavored,  but 
not  every  patient  can  stand  it.  The  sauce  is  prepared,  as  in  other 
roasts,  with  flour. 

13.  Roast  Fowl. — Fowl  destined  for  roasting  must  be  picked  and 
cleaned  immediately  after  killing,  and  then  it  is  allowed  to  hang  in 
a  cool  place  at  least  one  day;  in  winter,  two  to  four  days — for  which 
reason  one  should  always  inquire,  in  buying  dressed  poultry,  how 
long  it  has  been  killed. 

(a)  Young  cockerels  must  be  scalded  before  picking.  Before 
roasting,  the  hair  must  be  singed  off,  and  they  must  be  carefully 
washed  and  rubbed  with  salt  inside  and  outside ;  afterward  they  are 
put  in  a  pot  with  plenty  of  hot  butter,  roasted  brown  on  both  sides, 
with  frequent  basting,  for  which  three-quarters  to  one  hour  is  neces- 
sary. The  sauce  is  made  as  above,  with  a  little  flour.  One  hundred 
gm.  of  raw  chicken  equal  100  calories. 

(&)  Capons  and  pullets  should  be  roasted  with  little  butter,  since 
they  are  generally  fat  enough.  According  to  their  size  they  must 
be  roasted,  with  frequent  basting,  from  one  and  one-half  to  two 
hours.- 

(c)  Young  pigeons  are  treated  just  as  young  cockerels.  Time  of 
roasting,  about  three-quarters  of  an  hour. 

{d)  The  pheasant  yields  a  fine  roast  after  it  has  hung  about  eight 


270  DI^T  LISTS. 

to  fourteen  days.  Roast  it  from  two  to  three  hours,  with  plenty  of 
butter  and  frequent  basting. 

(e)  The  Partridge. — The  same  must  be  young,  and  must  have 
been  killed  several  days  before  using,  in  order  to  furnish  a  tender 
roast.  After  it  has  been  picked,  cleaned,  and  washed,  it  is  put  into 
a  tolerable  quantity  of  hot  butter,  and  a  piece  of  fresh  butter  is 
also  put  inside  the  partridge.  On  the  other  hand,  wrapping  with 
bacon  is  less  to  be  recommended  for  those  having  stomach 
trouble,  and  a  roast  just  as  juicy  can  be,  obtained  by  diligent 
basting;  the  palatability  can  also  be  increased  by  the  addition 
of  white  wine  and  sour  cream.  Time  of  roasting,  one  and  one- 
quarter  hours. 

(/)  Boiled  Cockerels  and  Pigeons. — They  are  prepared  just  as 
for  roasting,  then  laid  in  boiling,  slightly  salted  bouillon,  to  which 
a  little  julienne  has  been  added,  and  boil  one  to  one  and  one-quarter 
hours.  Very  young  pigeons  are  cooked  soft  in  three-quarters  of  an 
hour;  likewise  very  young  cockerels. 

14.  Roast  Game. 

(a)  Roast  Hare. — The  hare  is  skinned  and  then  cleaned,  but  the 
liver,  heart,  head,  etc.,  are  not  to  be  used  in  cooking  for  the  sick. 
After  the  roast  has  been  thoroughly  washed  within  and  without,  it 
is  well  salted  and  larded  with  fresh  (not  smoked)  bacon,  and  treated 
exactly  as  the  roast  lamb,  so  that  it  is  done  in  about  one  and  one- 
half  hours.  By  the  addition  of  sour  cream  the  roast  hare  becomes 
very  good,  but  in  this  way  it  does  not  agree  with  every  one.  The 
sauce  is  prepared  in  the  same  way  as  in  the  case  of  fillet  roast,  with 
flour  and  beef-tea. 

(b)  Roast  Venison  (Doe). — The  venison  saddle  is  the  most  bene- 
ficial game  for  those  who  have  stomach  troubles.  It  is  to  be  treated 
exactly  as  the  roast  hare,  only  it  must  be  roasted  about  two  and 
one-half  hours,  on  account  of  its  size.  The  joint  of  venison  will  gain 
considerably  in  tenderness  and  flavor  if  it  is  laid  in  light  red  wine  a 
few  days  before  using;  for  the  rest  it  is  to  be  treated  exactly  as  the 
venison  saddle,  only  it  must  be  roasted  two  and  one-half,  three,  or 
four  hours,  according  to  size.  The  sauce  is  the  same  as  with  roast 
hare.  But  game  can  also  be  treated  in  the  English  fashion,  by 
roasting  it  only  a  short  time,  as  in  the  case  of  fillet  and  roast  beef. 
A  venison  joint  thus  requires  one  and  one-quarter  hours,  approx- 
imately, with  strong  heat,  and,  if  very  heavy,  one  and  one-half 
hours.     A   venison   saddle,    if   young   and   tender,    requires   three- 


STEWED   MEATS.  271 

quarters  of  an  hour;  if  older,  one  and  one-quarter  hours.     In  this 
way  the  meat  remains  juicier  and  stronger. 

(c)  Venison  saddle  (stag)  is  to  be  treated  in  the  same  way,  except 
that  it  must  be  roasted  a  correspondingly  longer  time ;  but  generally 
the  meat  is  not  as  tender  and  palatable  as  that  of  the  doe.  One 
hundred  gm.  of  game  (roast)  equal  about  215  calories  (when  thor- 
oughly done). 

15.  Stewed  Meats. 

(a)  Preserved  Veal.— The  meat  from  a  leg  or  breast  which  has 
hung  sufficiently  is  cut  into  pieces  the  size  of  a  walnut;  the  latter 
are  put  into  a  small  stewpan  with  hot  butter,  and  a  little  salt  sprinkled 
over;  immediately  after  they  have  been  once  turned  in  the  butter, 
^  of  a  glass  of  white  wine,  about  75  gm.,  is  poured  in  and  the  whole 
covered  up  well  and  stewed  for  one  and  a  quarter  hours  with  moderate 
heat,  some  good  bouillon  being  added  from  -time  to  time.  One- 
quarter  of  an  hour  before  serving,  the  sauce  is  prepared  in  the  way 
before  indicated;  and  immediately  before  serving,  the  yolk  of  an 
&gg  is  mixed  with  water  and  put  into  the  sauce. 

(6)  Preserved  Sweetbread.— The  sweetbread  is  cooked  till  it  is 
soft  as  in  the  case  of  soup,  is  skimmed,  cut  into  two  halves,  and  ten 
minutes  before  serving  is  laid  in  butter-sauce,  to  be  prepared  in  the 
following  way:  A  little  piece  of  butter  is  melted  in  a  small  dish, 
without  being  allowed  to  brown;  then  one  tablespoonful  of  flour  is 
added,  well  mixed  with  the  butter;  then  pour  in  cold  bouillon  and 
a  little-  white  wine,  so  that,  after  the  sauce  has  boiled,  the  whole 
forms  a  tolerably  thick  liquid.  The  amount  of  the  ingredients  must 
be  determined  by  the  amount  of  sauce  desired.  Before  serving,  the 
yolk  of  an  &gg  is  added  to  the  sauce. 

(c)  Stewed  Cockerels  or  Pigeons.— A  young  cockerel  or  pigeon  is 
dressed  as  for  roasting,  quartered  into  equal  parts,  slightly  salted 
and  laid  in  a  stewpan  in  which  a  small  piece  of  butter  has  been  pre- 
viously melted  without  being  browned.  The  stewpan  is  covered 
tightly  and  the  poultry  stewed  slowly  for  a  quarter  of  an  hour. 
Then  ^  of  a  glass  of  white  wine,  about  75  gm.,  and  some  good  bouil- 
lon are  added,  and  it  is  again  allowed  to  stew  for  about  three-quarters 
of  an  hour  longer,  a  Httle  beef-tea  being  added  from  time  to  time. 
The  sauce  is  the  same  as  in  the  case  of  stewed  veal.  One  hundred 
gm.  of  meat  equal  about  120  calories. 

16.  Dishes  from  Chopped  Fresh  Meat.— Be  warned  against  allow- 
ing the  butcher  to  chop  the  meat,  as  in  some  cases  less  desirable  or 


2  72  DIET  LISTS, 

less  appetizing  meat  may  be  mixed  in.  Every  household  should 
possess  a  machine  for  chopping  meats ;  in  cases  where  there  is  none, 
do  not  mind  the  trouble  of  chopping,  or,  preferably,  scraping  it 
yourself. 

(a)  Roast  Chopped  Meat. — One-half  of  a  pound  of  veal,  ^  of  a 
pound  of  beef,  and  ^  of  a  pound  of  pork,  not  entirel}^  lean,  are  put 
through  the  chopping  machine;  the  whole  mass  is  then  mixed  in  a 
dish  with  three  whole  eggs,  ^  of  a  liter  of  milk,  i^  grated  rolls, 
and  a  tolerable  amount  of  salt;  if  the  dough  then  seems  too  stiff,  a 
little  more  milk  may  be  added.  The  mass  is  made  into  a  longish 
cake  and  roasted  in  hot  lard  or  good  butter  (loo  gm.)  first  on  one 
side  and  then  on  the  other,  until  it  is  light  brown.  Time,  one  hour 
and  a  quarter.  From  this  hardly  any  sauce  will  be  obtained ;  hence 
one  must  be  prepared  from  flour,  bouillon,  extract  of  meat,  and  a 
little  white  wine,  which  is  to  be  poured  over  a  quarter  of  an  hour 
before  serving.  One  hundred  gm.  of  this  roast  equal  about  250 
calories. 

(6)  Cutlets  from  Chopped  Meat. — The  same  mixture  as  in  the 
preceding  is  made  into  little  cutlets,  allowed  to  fry  on  both  sides  in 
hot  butter  until  light  brown;  then  skim  off  all  fat,  prepare  a  butter 
sauce,  pour  it  over,  and  let  it  fry  with  this  for  another  half -hour. 

(c)  Meat  Balls  (Veal). — One  pound  of  meat  from  the  leg  is  chopped 
up  fine  in  the  machine;  40  gm.  of  butter  are  stirred  to  foam,  two 
whole  eggs,  and  one  roll,  grated  fine,  are  added;  also  a  little  salt, 
and  according  to  taste  of  the  individual  a  little  finely  chopped  pars- 
ley. Of  this  mass  flat  cakes  are  made  and  cooked  for  one-quarter 
of  an  hour  in  salt  water;  butter  sauce,  or,  when  allowed,  anchovy 
sauce,  is  added,  which  is  to  be  poured  over  the  cakes  one-quarter  of 
an  hour  before  serving.     One  hundred  gm.  equal  250  calories. 

17.  Dishes  from  Chopped  Roast  Meat. 

(a)  Hash. — In  a  little  butter  or  lard  put  some  finely  chopped 
roast  meat  (veal,  fowl,  or  game),  stew  for  five  minutes  with  frequent 
stirring  and  pour  over  any  sauce  remaining  from  the  roast,  or  make 
a  special  sauce  as  follows :  Sprinkle  some  fine  flour  upon  the  stewed 
meat,  mix  well,  pour  in  a  little  white  wine  and  enough  bouillon  so 
as  to  produce  a  rather  thick  gruel.  Then  stew  for  one-quarter  of  an 
hour  longer  with  moderate  heat,  keeping  the  vessel  well  covered. 
The  hash  is  now  done.  A  little  extract  of  meat  added  will  improve 
the  flavor.     One  hundred  gm.  equal  about  225  calories. 

(6)  Meat  Pudding. — Sixty  gm.  of  butter  are  stirred  until  foamy, 


PREPARATION   OF   JELUES.  273 

four  yolks  of  eggs,  salt,  and  a  little  fine-cut  parsley  added.  Two 
French  rolls  are  grated  fine,  the  inside  cut  into  small  pieces  and 
soaked  in  milk,  in  which  it  remains  one  hour ;  1 70  gm.  of  roast  meat 
are  cut  fine  or  chopped  in  a  machine;  the  grated  rolls  are  taken  out 
of  the  milk,  pressed,  and  with  the  chopped  roast  meat  mixed  with 
the  other  mass  (butter  and  eggs).  If  allowed,  two  tablespoonfuls 
of  sour  cream  may  also  be  added.  Lastly,  the  whipped  whites  of 
four  eggs  are  mixed  in,  and  the  whole  dough  is  put  in  a  mold  rubbed 
with  butter  and  stewed  with  dust  from  the  rolls.  In  this  the  pudding 
is  cooked  for  one  and  three-quarter  hours  in  a  water-bath.  Any 
sauce  remaining  from  a  roast  is  added  (or  anchovy  sauce).  One 
hundred  gm.  equal  about  200  calories. 

(c)  Omelette  Souffle  from  Remnants  of  Roasts. — Forty  gm.  of 
finely  cut  roast  meat  are  mixed  with  one  tablespoonful  of  sweet  or 
sour  cream ;  a  little  salt  and  the  yolk  of  an  egg  are  added ;  the  whipped 
white  of  an  egg  is  mixed  in;  the  mass  is  put  into  a  small  porcelain 
mold  and  baked  in  a  well-heated  oven  for  twenty  minutes;  sauce 
from  a  roast  is  added.     The  whole  mass  equals  215  calories. 

(d)  Sweetbread  Pudding  (according  to  Hedwig  Hehl). — Twenty- 
five  gm.  of  French  rolls  are  grated  and  laid  in  milk.  The  sweet- 
bread is  cooked,  until  soft,  in  bouillon  or  salt  water,  skinned,  and 
cut  into  small  blocks.  Thirty  gm.  of  butter  are  stirred  until  foamy, 
and  two  yolks  of  eggs,  the  roll  which  has  been  pressed  out,  a  little 
salt,  parsley,  and  the  blocks  of  sweetbreads  are  put  into  the  butter, 
with  which  the  whipped  white  of  an  egg  is  mixed;  the  whole  is  put 
into  a  cup  well  rubbed  with  butter,  covered,  and  cooked  for  three- 
quarters  of  an  hour  in  the  water-bath.  Anchovy  sauce  or  meat 
gravy  is  added.     One  hundred  gm.  equal  about  150  calories. 

IV.  Jellies. 

I.  Wiel's  Jelly,  for  Dyspeptics. — Take  off  the  skin  and  meat  from 
a  calf's  foot,  mash  the  bones,  and  put  on  the  stove  with  some  cold 
water  until  it  is  heated  to  foaming,  when  all  refuse  will  be  sepa- 
rated. After  rinsing  off  the  scum  with  cold  water,  put  the  bones 
with  I  of  a  k.  of  beef,  or  ^  of  an  old  hen,  and  i^  liters  of  water, 
and  five  gm.  of  salt,  and  boil  slowly  from  four  to  five  hours.  Pour 
the  jelly  thus  formed  through  a  fine  sieve,  and  place  overnight  in 
the  cellar.  Next  morning  take  off  the  layer  of  fat,  and  to  clarify  the 
cold  jelly  add  one  egg  with  the  mashed  shell,  and  mix  with  steady 
beating  and  stirring.     Then  subject  the  whole  with  constant  beating 


274  I^ISI'  IvISTS. 

and  stirring  to  a  temperature  of  not  over  60°  R.  (or  else  the  white 
of  the  egg  will  curdle).  If  the  jelly  begins  to  show  grains,  cover 
and  let  cool  until  the  white  of  egg  becomes  flaky  and  separates. 
Hereupon  strain  a  few  times  more  until  it  becomes  perfectly  clear, 
add  five  gm.  of  extract  of  meat,  and  pour  the  jelly  into  a  mold  and 
let  cool  again.  An  addition  of  gravy  from  a  roast  is  very  palatable. 
It  must  be  mixed  in  while  the  mass  is  still  warm  and  liquid.  The 
dish  is  very  palatable  with  cold  fowl,  but  does  not  keep  well  in 
summer,  and  had,  therefore,  best  be  put  on  ice. 

2.  Ichthyocolla  Jelly. — Cut  fifteen  gm.  of  ichthyocoUa  into  small 
pieces  and  let  soften  in  ^  of  a  liter  of  cold  water  for  eight  to  ten 
hours;  boil  for  one-quarter  of  an  hour  and  add  gravy  from  a  roast 
and  extract  of  meat.  Pour  the  mass  when  hot  through  a  fine  cloth, 
or,  better,  through  filter-paper.  One  can  add  to  100  gm.  of  the 
liquid  also  0.5  gm.  of  hydrochloric  acid  or  ten  gm.  of  white  wine. 

3.  Milk  Jelly. — Boil  two  liters  of  milk  for  five  to  ten  minutes  with 
250  gm.  of  sugar.  To  the  well-cooled  mixture  add,  while  slowly 
stirring,  a  solution  of  thirty  gm.  of  white  gelatin  in  250  gm.  of  water, 
and  also  add  three  wineglassfuls  (400  gm.)  of  good  Rhine  wine,  or 
thirty  gm.  of  cognac;  afterward  pour  the  mass  into  a  form  and  let 
cool.     One  hundred  gm.  equal  about  250  calories. 

V.  Vegetables. 

1.  Asparagus. — The  asparagus  stems  are  washed,  peeled  from  the 
top  downward,  and  the  lower  woody  ends  cut  off;  then  they  are 
bound  in  a  small  bundle,  and  cooked  until  soft  in  salt  water,  which 
requires,  according  to  the  thickness  of  the  stems,  one-half  to  one 
hour;  a  large  quantity  of  water  must  be  used  in  cooking,  otherwise 
the  asparagus  easily  takes  an  ugly  color.  Make  a  butter  sauce  with 
yolk  of  egg.  Dyspeptics  can  take  only  the  soft  heads  without  sauce. 
One  hundred  gm.  equal  about  20  calories. 

2.  Spinach. — The  spinach  leaves  are  carefully  picked,  washed,  and 
laid  in  boiling  salt  water,  in  which  they  are  to  be  cooked  slowly, 
without  being  covered ;  otherwise  they  lose  their  color  easily.  After 
twenty  minutes  put  them  on  a  sieve,  pour  cold  water  over  them,  and 
press  them.  Then  cut  the  spinach  very  fine  or  pass  through  a  hair 
sieve,  lay  in  a  little  melted  butter,  dust  flour  over  it  several  times, 
and  add  strong  bouillon.  Lastly,  mix  in  the  yolk  of  an  egg  with 
cold  bouillon.  One  hundred  gm.  equal  165  calories  (prepared  from 
250  gm.  of  spinach  leaves). 


PREPARATION  OF  VEGETABLES.  275 

3.  Comfrey  or  Bruisewort. — Wash,  clean  carefully,  cut  in  pieces 
two  inches  long,  and  also  split  the  thicker  pieces  lengthwise.  Mix 
one  tablespoonful  of  flour  with  one  liter  of  water  and  one  table- 
spoonful  of  vinegar,  and  lay  each  cleaned  piece  of  root  in  the  mix- 
ture. Afterward  they  are  again  rinsed  on  a  sieve  with  clean  water, 
laid  in  melted  butter,  salted,  covered  tightly  and  stewed,  adding 
strong  bouillon  from  time  to  time.  According  to  size  and  age  the 
roots  require  boiling  from  three-quarters  to  one  and  one-half  hours 
in  order  to  become  soft.     One  hundred  gm.  equal  about  120  calories. 

4.  Green  Peas. — The  peas  (^)  are  hulled  and  stewed  in  15  gm.  of 
butter  and  bouillon  as  the  preceding;  time,  from  one  to  one  and 
a  half  hours.  Or,  take  canned  peas  and  put  the  opened  can  in  hot 
water,  or  cook  them  with  the  same  amount  of  butter  and  some  salt. 
For  the  sick  it  is  advisable  to  pass  the  peas  through  a  sieve  and  serve 
them  as  a  puree.  One-half  of  a  liter  of  peas  yield  280  gm.  of  pea 
puree;  of  this,  100  gm.  equal  160  calories. 

5.  Carrots. — Carrots  are  serviceable  in  the  dietetic  kitchen  only 
when  very  young  and  tender.  They  are  cleaned,  washed,  cut  into 
pieces  and  then  stewed  similarly  to  peas.  The  time  is  also  the 
same.  If  it  is  desired  to  serve  them  as  a  puree,  they  are  passed 
through  a  hair  sieve  after  they  are  cooked.  A  little  flour  is  dusted 
over  them  and  they  are  cooked  to  a  thick  mush.  One  hundred  gm. 
of  puree  equal  120  calories. 

6.  Beans  (Green). — Young  beans  are  cleaned,  washed,  cut  flne, 
and,  like  the  peas,  stewed  in  butter  and  bouillon.  In  a  season  when 
there  are  no  young,  fresh  vegetables,  one  can  use  to  advantage 
canned  beans,  of  which  Prince  beans  (Flagiolettes)  are  the  most 
tender.     One  hundred  gm.  equal  about  40  calories. 

7.  Cauliflower. — The  cauliflower  is  cleaned,  washed,  and  treated 
like  the  asparagus.  Time  of  cooking,  one-half  hour.  One  hundred 
gm.  equal  about  60  calories. 

8.  Rice  in  Bouillon. — Thirty  gm.  of  rice  are  washed  twice  on  the 
previous  evening,  and  then  water  in  which  a  little  carbonate  of  soda 
has  been  dissolved  is  poured  over  it,  so  that  the  rice  may  swell  during 
the  night;  then  the  water  is  drained  off,  and  the  rice  with  a  piece 
of  butter  and  some  strong  bouillon  is  put  in  a  stewpan  and  stewed 
for  one  and  one-quarter  hours,  tightly  covered,  except  the  last 
quarter  of  an  hour;  finally  the  beaten-up  yolk  of  an  egg  is  added. 
Now  rinse  out  a  small  porcelain  dish  with  cold  water,  without  drying 
it,  and  press  the  rice  into  it,  let  stand  five  minutes  and  then  turn 


276  DIETETIC   KITCHEN. 

the  mold.  The  amount  is  calculated  for  one  person,  and  is  best 
suited  for  a  side  dish  to  meats.  The  whole  equals  about  225  calories. 
9.  Chestnut  Puree. — One-half  kilo  of  chestnuts  are  peeled  and 
boiled  in  water  so  long  as  to  get  the  second  (inside)  skin  off  easily. 
The  chestnuts  are  laid  upon  a  sieve  until  all  the  water  has  drained 
off.  Then  they  are  mashed  in  a  dish  and  afterward  pressed  through 
a  hair  sieve.  One  hundred  gm.  of  butter  are  melted  in  a  stewpan 
on  the  fire;  a  little  salt  and  sugar,  enough  to  cover  the  point  of  a 
knife,  are  added  (to  the  butter),  and  then  the  chestnuts  are  put  in. 
Stew  them,  with  frequent  stirring,  for  one-half  hour,  and  pour  in 
enough  bouillon  to  get  a  mush  not  too  thick. 

VI.  Side  Dishes  from  Eggs  and  Flour. 

1.  Scrambled  Eggs. — Two  eggs  are  thoroughly  beaten  with  a  little 
salt  until  the  yolk  and  white  are  completely  mixed.  Then  melt 
five  gm.  of  butter  in  a  small  enameled  vessel,  add  the  ^gg  mixture, 
and  heat,  with  continued  stirring,  until  a  rather  thick  mush  is  formed. 
Serve  in  a  well-warmed  dish.  This  dish  is  suitable  with  cold  roast, 
ham,  smoked  meat,  etc.  Two  scrambled  eggs  equal  about  200 
calories. 

2.  Potato  Puree. — Peel  f  of  a  pound  of  very  mealy  potatoes,  cut 
into  quarters,  wash,  and  cook  until  soft  in  a  steam-cooking  apparatus; 
then  pass  through  a  coarse  hair  sieve;  add  20  gm.  of  fresh  butter,  a 
little  salt,  and  60  to  70  gm.  of  warm  milk,  and  beat  thoroughly  for 
five  minutes  while  the  mixture  is  on  the  fire,  until  it  becomes  very 
foamy.  This  must  only  be  prepared  just  before  serving,  as  it  loses 
flavor  in  standing.     One  hundred  gm.  equal  about  125  calories. 

3.  Suahian  Dumplings. — One  hundred  gm.  of  flour,  two  eggs,  two 
tablespoonfuls  of  milk,  and  a  little  salt  are  thoroughly  stirred  to- 
gether; the  dough  is  put  in  a  special  sieve  (coarse),  through  which 
it  is  forced  and  allowed  to  drop  into  strongly  salted  boiling  water. 
One  must  take  a  large  pot  with  plenty  of  water,  so  that  the  dumphngs 
may  rise  better;  they  are  allowed  to  boil  for  half  an  hour.  When 
done  they  are  poured  on  a  large  sieve,  and  remain  until  all  the  water 
has  drained  off.  Meanwhile  melt  in  a  stewpan  ten  gm.  of  fresh 
butter,  put  the  dumplings  into  it,  shake  them  well,  and  serv^e.  The 
sieve  necessary  is  known  only  in  South  Germany,  but  it  can  be  made 
by  any  tinner,  for  it  is  like  an  ordinary  strainer,  the  holes  having  a 
diameter  of  one  cm.  (about  f  of  an  inch).  One  hundred  gm.  equal 
175  calories. 


EGG   AND   FLOUR    SIDE    DISHES.  277 

4.  Roll  Dumplings. — Rolls  from  the  day  before  are  grated  (that  is, 
the  crust),  the  inside  is  cut  into  slices  and  cold  milk  poured  over  until 
the  bread  is  thoroughly  soft,  for  which  at  least  an  hour  is  necessary. 
Meanwhile  stir  60  gm.  of  butter  for  one-quarter  of  an  hour,  and 
add  slowly  four  eggs  and  a  little  salt.  Then  squeeze  the  milk  out 
of  the  slices  and  stir  them  with  the  butter  and  eggs  until  finely 
divided.  In  order  to  test  whether  the  mass  be  of  the  right  con- 
sistency, make  a  lump  as  large  as  a  walnut  and  boil  in  salt  water. 
If  it  breaks,  a  little  dust  from  grated  rolls  must  be  added.  When 
the  dough  has  acquired  the  necessary  firmness,  make  dumplings  the 
size  of  an  apple  (about  seven  from  the  given  quantity  of  ingredients) . 
After  they  have  boiled  well  for  one-quarter  of  an  hour  in  salt  water, 
take  them  out  with  a  sieve  spoon,  cut  in  half,  and  serve.  One 
hundred  gm.  equal  250  calories. 

5.  Vermicelli  (Water  Noodles  or  Vegetable  Noodles). — For  the  dough 
take  180  gm.  of  flour,  and  three  eggs,  which  are  to  be  mixed  with 
the  flour  in  a  dish ;  then  put  the  dough  on  a  board,  and  knead  well 
with  the  hands  until  it  is  tender.  Then  form  it  in  the  shape  of  a  long 
sausage  and  cut  into  four  equal  parts.  First  take  one  part:  knead 
into  a  flat,  round  cake;  weigh  off,  in  addition,  20  gm.  of  flour;  dust 
the  board  and  rolling-pin  with  this,  and  roll  out  thin  (20  gm.  of 
flour  will  suffice  for  all  the  four  parts  of  the  dough) .  At  each  turning 
of  the  dough  dust  the  board  again  with  flour,  so  that  the  dough  may 
not  stick  and  tear.  The  necessary  thinness  is  reached  when  one  can 
distinguish  through  the  dough  the  pattern  of  a  piece  of  calico,  etc., 
laid  uiiderneath.  When  thin,  lay  the  four  parts  on  a  clean,  white 
cloth  near  the  fire;  let  them  become  half  dry,  and  cut  into  strips 
one  cm.  broad,  which  are  to  be  separated  and  hung  up  in  the  kitchen 
for  twelve  hours  to  dry.  They  can  be  kept  for  some  time  in  a  tureen. 
When  using,  lay  them  for  ten  minutes  in  boiling  salt  water ;  pour  off 
the  water  through  a  strainer,  and  put  the  noodles  in  a  dish.  Vege- 
table noodles  of  a  very  good  quality  are  now  also  made  by  factories. 
One  hundred  gm.  of  boiled  noodles  equal  about  190  calories. 

6.  Macaroni. — Buy  only  the  best  quality.  Put  in  a  vessel  with 
much  boiling  water,  and  after  it  has  boiled  ten  minutes  pour  off 
the  water;  pour  over  some  more  boiling  salt  water  and  let  boil  for 
half  an  hour.  Drain,  put  in  a  stewpan  with  a  little  butter  (which 
is  on  the  fire),  mix,  and  serve  immediately.  One  hundred  gm.  equal 
about  1 50  calories.  One  can  also,  instead  of  putting  hot  butter  over 
the  macaroni,  add  a  butter  sauce,  described  under  "presers^ed  sweet- 


27< 


DIETETIC    KITCHEN. 


bread."  When  the  macaroni  has  been  drained,  put  in  a  porcelain 
dish  in  which  it  is  serv^ed,  pour  the  thickish  sauce  over  and  put  the 
dish  for  ten  minutes  in  the  oven. 

VII.  Flour,  Milk,  and  Egg  Dishes. 

1.  Rice  Mush. — Thirty  gm.  of  rice  (CaroHne  rice  is  the  best)  are 
twice  thoroughly  washed  the  night  before ;  then  cold  water,  in  which 
a  little  carbonate  of  soda  has  been  dissolved,  is  poured  over,  and 
allowed  to  stand  until  the  next  day.  Before  using,  the  water  is 
poured  off;  ^  of  a  liter  of  milk  is  boiled  and  the  rice  then  added 
and  boiled,  well  covered  up,  for  one  and  one-quarter  hours  on  a 
moderate  fire,  with  frequent  shaking.  If  the  milk  becomes  too 
thick  from  boiling  before  the  rice  has  been  thoroughly  softened,  add 
a  little  more  hot  milk.  AVhip  the  whites  of  two  eggs,  and  just  before 
serving  mix  lightly  with  the  rice;  if  it  is  desired  to  make  it  more 
nourishing,  the  yolks  of  the  two  eggs  can  also  be  added  before  the 
whites  (this  quantity,  for  one  person,  equals  700  calories).  One 
hundred  gm.  equal  about  160  calories. 

2.  Tapioca. — Boil  i  of  a  Hter  of  milk;  mix  20  gm.  of  best  imported 
tapioca  and  boil  for  one-quarter  of  an  horn-  longer,  with  constant  stir- 
ring. Further  procedure  same  as  with  rice  (in  the  same  way  oatmeal 
also  may  be  treated) .     Value  in  calories  of  above  quantity,  about  2  50. 

3.  White  Po^.— Moisten  in  a  small,  well-enameled  pan  65  gm.  of 
fine  sugar  with  one  tablespoonful  of  water,  and  burn  to  caramel 
sugar.  This  requires  great  care,  for  the  sugar  easily  becomes  too 
dark  and  then  takes  on  a  bitter  taste.  On  a  hot  stove,  not  over  an 
open  fire,  one  must  constantly  stir  the  sugar  with  a  tin  spoon  until  it 
gets  a  fine  brown  color.  During  this  process  heat  a  tin  form,  such 
as  are  usually  used  for  sweet  dishes,  jelly,  etc.,  and  pour  into  it  the 
sugar  as  soon  as  it  has  browned,  and  let  it  spread  on  all  sides  until 
the  surface  of  the  plate  is  covered.  Then  let  cool.  Now  beat  up 
three  whole  eggs  in  a  dish,  add  ^  of  a  liter  of  unboiled  milk,  the 
contents  of  a  package  of  vanilla,  or  ^  of  a  stick  of  vanilla  boiled 
in  milk,  powdered  sugar  to  taste,  mix  the  whole  thoroughly,  and 
pour  into  the  form  with  the  sugar,  which  is  now  cold.  Put  on  a 
water-bath,  cover,  and  boil  until  the  mass  has  amalgamated,  which 
can  be  tried  by  thrusting  in  a  teaspoon.  Take  out  the  form,  allow 
it  to  cool,  and  turn  over  on  a  plate.  This  is  a  pleasant,  cooling, 
well-tasting  dish,  nourishing  as  well  as  easily  digestible.  One  hun- 
dred gm.  equal  about  30  calories. 


PREPARATION    OF   PUDDINGS.  279 

4.  Egg  Creme  (according  to  Mrs.  Dr.  Pariser). — For  this  one  reckons, 
for  one  person,  one  yolk  of  egg,  two  tablespoonfuls  of  beaten  cream 
flavored  with  vanilla,  sugar  according  to  taste,  and  a  few  drops  of 
arrack  or  cognac.  The  yolk  of  egg  is  first  beaten  with  sugar  to  foam. 
Then  the  whipped  cream  is  added  and  well  mixed  in;  lastly,  a  few 
drops  of  arrack  or  cognac  are  added,  and  the  whole  served  in  wine- 
glasses. 

5.  Vanilla  Crime  (according  to  Mrs.  Dr.  Hughes). — Stir  four  yolks 
of  eggs  to  foam,  with  -|-  of  a  pound  of  fine  sugar;  boil  j  of  a  liter 
of  milk  with  some  vanilla  and  add  immediately  to  the  eggs;  mix 
with  an  egg-beater  and  again  put  on  the  fire,  with  continual  stirring. 
Six  pieces  of  white  gelatin  are  dissolved  in  a  little  hot  water  and 
poured  into  the  mass  while  the  latter  is  still  on  the  fire.  As  soon  as 
it  is  risen,  take  quickly  from  the  fire,  pour  through  a  strainer  and 
nearly  allow  it  to  cool,  with  constant  stirring.  Then  the  whipped 
whites  of  four  eggs  are  added  and  the  mass  poured  into  a  porcelain 
dish  which  has  been  rinsed  with  cold  water;  allow  it  to  cool,  and 
turn  over  just  before  using.  A  fruit  sauce  may  be  served  with  the 
creme. 

6.  Roll  Pudding. — Stir  thirty  gm.  of  butter  until  foamy,  add  yolks 
of  two  eggs,  with  one  tablespoonful  of  fine  sugar,  fifteen  gm.  of 
grapes,  fifteen  gm.  of  raisins,  and  twenty  gm.  of  finely  grated  almonds. 
The  outsides  of  two  French  rolls  are  grated  off,  the  insides  cut  in 
pieces,  soaked  one  hour  in  milk,  and  then  squeezed  thoroughly  and 
mixed  with  the  rest  of  the  mass.  Now  the  whole  is  thoroughly 
mixed,  the  whipped  w^hites  of  two  eggs  stirred  in,  and  the  dough  put 
into  a  form  rubbed  with  butter  and  dusted  with  roll  dust.  Either 
bake  the  pudding  for  three-quarters  of  an  hour  in  the  water-bath  or 
bake  in  a  small  porcelain  dish  for  one-half  of  an  hour  in  an  oven. 
Add  vanilla  or  wine  sauce.  If  necessary,  the  almonds,  raisins,  and 
grapes  may  be  omitted.     One  hundred  gm.  equal  about  250  calories. 

7.  Tapioca  Pudding. — Thirty-five  gm.  of  tapioca  are  cooked  for 
five  to  seven  minutes  with  j  of  a  liter  of  milk  until  it  turns  to  a 
thick  mush.  Meanwhile  stir  to  foam  twenty-five  gm.  of  butter ;  add 
yolks  of  two  eggs  and  one  small  tablespoonful  of  fine  sugar,  and  stir 
this  mass  into  the  no  longer  hot,  but  still  warm,  mush.  After  rub- 
bing a  small  porcelain  form  with  butter,  whip  the  whites  of  two 
eggs,  add,  and  mix  with  the  mass.  Put  into  the  form  and  bake  the 
pudding  in  a  well-heated  oven  for  three-quarters  of  an  hour.  One 
hundred  gm.  equal  175  calories. 

19 


28o  DIETETIC   KITCHEN. 

8.  Flour-mush  Pudding. — Melt  twenty  gm.  of  butter  in  a  saucepan ; 
mix  in  smoothly  fifty  gm.  of  flour  and  |^  of  a  liter  of  milk,  and 
cook  the  mush  until  it  separates  from  the  pan.  Then  let  cool  a  little, 
and  add  afterward  one  yolk  of  egg.  Now  stir  until  foamy  twenty 
gm.  of  butter,  to  which  add  yolks  of  two  eggs,  i^  tablespoonfuls  of 
sugar  and  one  teaspoonful  of  arrack,  and  with  this  mass  mix  the 
cooked  mush;  then  whip  the  whites  of  the  three  eggs,  mix  lightly 
with  the  mass,  fill  into  a  form  rubbed  with  butter  and  dusted  with 
roll  dust,  and  let  cook  for  one  hour  in  the  water-bath.  One  hundred 
gm.  equal  about  220  calories. 

9.  Rice  Pudding. — Thirty-five  gm.  of  finest  rice  is  soaked  the 
night  before,  as  in  the  case  of  rice  mush.  Heat  ^  of  a  liter  of  milk, 
add  the  rice;  cover  and  cook  slowly  until  entirely  soft;  stir  25  gm. 
of  butter  to  foam,  add  two  yolks  of  eggs  attd  one  tablespoonful  of 
sugar.  When  the  rice  has  become  lukewarm,  mix  in  the  other  mass ; 
whip  two  whites  of  eggs,  put  the  dough  in  a  porcelain  form  rubbed 
with  butter,  and  bake  in  an  oven  for  half  an  hour.  One  hundred 
gm.  equal  about  150  calories. 

10.  Biscuit  Pudding. — Five  yolks  of  eggs  are  stirred  for  half  an 
hour  with  ^  of  a  pound  of  fine  sugar ;  then  add  a  small  tablespoonful 
of  fine  flour  and  a  little  vanilla ;  also  a  little  arrack  and  five  whipped 
whites  of  eggs.  Rub  a  pudding  form  with  butter  and  dust  with  fine 
roll  crumbs ;  fill  in  the  mass  and  cook  for  one  hour  in  the  water-bath. 
One  hundred  gm.  equal  215  calories. 

11.  Noodle  Pudding. — Of  the  best  egg  noodles  (fine)  take  seventy 
gm.,  crumble  to  pieces,  throw  into  ^  of  a  liter  of  boiling  milk,  and 
boil  for  half  an  hour.  Meanwhile  stir  50  gm.  of  butter  until  foamy, 
add  three  yolks  of  eggs  and  about  one  tablespoonful  of  fine  sugar, 
and  mix  this  mass  with  the  half-cooled  mush.  At  last  whip  the 
whites  of  three  eggs,  mix  with  the  rest,  put  the  whole  in  a  form 
rubbed  with  butter,  and  bake  the  pudding  for  one  hour  in  the  oven. 

12.  Omelette  Souffle. — Stir  the  yolk  of  an  egg,  with  one  tablespoon- 
ful of  fine  sugar,  for  a  quarter  of  an  hour ;  add  on  the  point  of  a  knife 
a  little  of  the  finest  flour,  one  tablespoonful  of  arrack,  and  the  whipped 
whites  of  i^  eggs.  In  an  omelette  pan,  melt  five  gm.  of  butter, 
and  meanwhile  put  on  the  hearth  a  porcelain  soup  plate,  which 
must  fit  the  pan  exactly,  and  heat  the  plate  well.  Then  put  the 
dough  in  the  pan  and  cover  this  immediately  with  the  hot  plate. 
Now  bake  the  omelette  with  a  moderate  fire  until  the  surface  has 
become  solid,  which  requires  four  or  five  minutes ;  then  turn  over  on 


MISCELLANEOUS    PREPARATIONS.  28 1 

another  warmed  flat  plate ;  then  fold  in  the  middle,  strew  sugar  over, 
and  serve  at  once.     The  whole,  about  240  calories. 

13.  Souffle  Baked  in  the  Oven. — Stir  the  yolks  of  two  eggs,  with 
35  gm.  of  sugar,  for  a  quarter  of  an  hour;  add  on  the  point  of  a  knife 
a  little  fine  flour,  and  one  tablespoonful  of  arrack  and  the  whipped 
whites  of  two  eggs ;  then  at  once  fill  the  dough  into  a  porcelain  form 
rubbed  with  butter,  and  bake  for  eight  to  ten  minutes  in  the  oven. 
The  whole,  about  370  calories. 

14.  Snowballs  in  Vanilla  Crime. — One  liter  of  milk,  with  one 
tablespoonful  of  fine  sugar,  mixed,  is  used  in  the  cooking.  The 
whites  of  four  eggs,  with  one  tablespoonful  of  sugar,  are  whipped 
until  stiff.  Then  from  the  whipped  eggs  longish  lumps  are  cut  out 
with  a  tin  spoon  and  these  put  into  the  boiling  milk.  The  milk  must 
be  put  on  the  fire  in  a  large,  wide  can  so  that  the  snowballs  may 
expand.  One  must  never  put  more  than  six  in  the  pan  at  one  time. 
When  they  have  lain  one  minute  in  the  milk,  turn  them;  let  them 
lie  another  minute  on  the  other  side,  take  them  out  carefully,  and 
lay  on  a  large  platter.  After  the  whole  has  thus  been  treated,  take 
the  four  yolks  of  eggs,  mix  with  a  teaspoonful  of  fine  flour,  ^  of  a 
liter  of  milk,  and  a  package  of  vanilla,  and  make  of  them  a  crime. 
When  this  begins  to  boil  take  it  from  the  fire;  let  it  cool,  and  just 
before  serving  place  the  snowballs  upon  the  crime  in  a  porcelain 
dish. 

VIII.  Miscellaneous. 

1.  Stewed  Apples. — Peel  good  apples,  cut  them  and  stew  with  a 
little  water  and  sugar,  according  to  taste ;  then  pass  through  a  coarse 
hair  sieve.     One  hundred  gm.  equal  about  seventy-five  calories. 

2.  Pears. — Peel  good  pears,  cut  in  halves,  but  do  not  take  out 
seeds,  put  on  the  fire  with  plenty  of  water  and  a  little  sugar,  and 
boil  until  soft;  a  little  wine  added  will  improve  the  palatability. 

3.  Wine  Sauce  or  Chandeau. — Two  yolks  of  eggs  are  beaten  up 
in  a  small  pan  with  ^  of  a  teaspoonful  of  the  finest  potato  flour; 
then  slowly  stir  in  i  of  a  liter  of  good  wine  and  add  two  to  three 
tablespoonfuls  of  fine  sugar.  Put  on  the  fire  and  stir  until  the  sauce 
has  gained  a  thick  consistency;  then  immediately  take  from  the 
fire  and  cover ;  now  whip  two  whites  of  eggs,  and  pour  the  sauce  into 
this  slowly,  with  vigorous  stirring,  and  serve  at  once.  Reckoning 
the  value  in  calories  of  the  alcohol,  100  gm.  equal  about  1 10  calories. 

4.  Vanilla  Sauce. — Mix  two  yolks  of  eggs  with  one  tablespoonful 


282  DIETETIC    KITCHEN. 

of  fine  sugar,  add  J  of  a  liter  of  cold  milk,  a  little  vanilla  or  ^  of 
a  package  of  vanillin.  The  sauce  is  put  on  the  fire  and  stirred  until 
it  begins  to  thicken.  Then  take  from  the  fire  immediately  and 
serve.     One  hundred  gm.  equal  about  125  calories. 

5.  Aleuronat  Bread  (according  to  Dr.  Huth,  "Aerztl.  Centralbl.," 
August,  1894,  No.  46). — Mix  500  gm.  of  aleuronat  flour  and  1500- 
gm.  of  rye  flour;  mix  one-half  of  this  mass  with  one  liter  of  warm 
water,  two  good  tablespoonfuls  of  salt,  and  180  gm.  of  yeast  finely 
divided  in  a  little  water;  set  this  dough,  sprinkled  with  a  little  flour,, 
to  rise.  After  the  usual  rise  the  dough  is  worked  up  with  the  remain- 
ing flour  into  two  loaves.  These  are  baked  in  square  pans  (10,  15, 
20  cm.)  rubbed  with  butter;  after  letting  them  rise  well  once  more,, 
they  are  baked  for  two  hours  with  strong  heat. 

6.  Nutritive  Enemata: 

(a)  Meat  Pancreas  Clyster  (according  to  I^eube). — One  hundred 
and  fifty  gm.  of  good  beef  are  scraped  and  then  chopped  fine;  50 
gm.  of  fresh  pancreatic  gland,  free  from  fat  (either  of  a  cow  or  of  a 
hog),  are  mixed  with  this  and  stirred  carefully,  with  the  addition  of 
not  more  than  150  gm.  of  lukewarm  water.  Injections  of  from  50 
to  not  more  than  100  gm.  at  a  time,  in  a  lukewarm  state,  by  means 
of  a  simple  funnel,  ending  in  a  nozzle  which  must  have  a  wide  open- 
ing. The  mixture  will  keep  only  a  short  while.  One  hundred  gm. 
equal  about  120  calories. 

(6)  Nutritive  Enema  (according  to  Ewald). — Two  or  three  eggs 
are  beaten  smooth  with  one  tablespoonful  of  cold  water  and  a  little 
salt — as  much  as  can  be  held  on  the  point  of  a  knife.  Wheaten 
starch,  as  much  as  can  be  held  on  the  point  of  a  knife,  is  boiled  with 
^  of  a  cup  (100  gm.)  of  a  20  per  cent,  solution  of  grape  sugar  and 
one  wineglass  (150  gm.)  of  red  wine  added.  Then  the  solution  is 
cooled  to  30°  R.,  and  the  eggs  are  stirred  in  slowly.  One  can  add 
also  one  teaspoonful  of  meat  peptone,  but  this  is  not  absolutely 
necessary.  Nutritive  clysters  are  to  be  injected  while  at  blood  heat 
and  in  quantities  of  250  gm.  at  a  time.  Previously  the  rectum  must 
have  been  cleansed  by  a  purgative  clyster.  The  addition  of  grape  sugar 
had  better  be  omitted,  since  through  it  decomposition  and  irritations 
of  the  intestines  arise  (Wegele).     It  contains  about  400  calories.* 

*  In  calculating  the  value  in  calories  of  the  nutritive  clysters  it  is  to  be  noted  that  the 
amount  of  resorption  is  difficult  to  determine,  since  it  depends  upon  the  state  of  the 
intestines,  the  skill  of  the  patient  in  retaining  the  enema,  etc.  It  is  therefore  well  to- 
assume  only  one-half  as  resorbed. 


MISCELLANEOUS   PREPARATIONS.  283 

(c)  Nutritive  Clyster  (according  to  Boas). — Warm  250  gm.  of 
milk,  stir  with  two  yolks  of  eggs,  one  teaspoonful  of  common  salt, 
and  one  tablespoonful  of  wheaten  starch,  and  afterward  add 
one  tablespoonful  of  red  wine.  If  the  mucous  membrane  of  the 
rectum  is  easily  irritated,  one  may  add  four  to  five  drops  of 
tincture  of  opium.  Such  clysters  may  be  administered  from  one 
to  four  times  in  twenty-four  hours  (heated  to  blood  heat),  with  a 
long,  soft,  rectal  tube  and  a  Heger's  funnel.  Contains  about  four 
hundred  calories. 

(d)  Meat  Bouillon- wine  Clyster  (according  to  Kleiner). — This  con- 
sists of  eighty  gm.  of  beef-tea  and  forty  gm.  of  mild  white  wine;  to 
be  injected  two  or  three  times  a  day  at  body-heat.  According  to 
Kleiner,  these  clysters  bring  sleep  to  weakened  patients. 

7.  Alcoholic  Pancreas  Extract  (according  to  Dr.  Reichmart). — A 
fresh  ox  pancreas  is  freed  from  fat  and  skin  immediately  after  kill- 
ing, chopped  up,  and  ^  of  a  liter  of  12  to  15  per  cent,  alcohol  is 
poured  over.  Let  stand  two  to  three  days  in  a  cool  place,  and  filter. 
One  wineglass  for  each  meal. 

The  following  is  a  meat  food  recommended  in  the  absence  of 
secretion  of  hydrochloric  acid: 

Meat  Dumplings  with  Sardelle  Dressing  (according  to  Mrs.  J.  C. 
Hemmeter). — Take  J  of  a  cup  of  finely  scraped  beef,  -J  of  a  cup  of 
lean  pork  ground  through  the  meat-chopper.  Add  salt  and  a  sm^all 
amount  of  nutmeg;  2^  ounces  of  butter  creamed,  yolks  of  two  eggs 
creanled ;  two  ounces  of  stale  bread  soaked  in  cold  water ;  after  it  is 
softened  press  it  dry  and  add  to  the  meat;  then  add  the  beaten 
white  of  two  eggs  and  mix  all  thoroughly.  Turn  into  thirty  dump- 
lings and  boil  for  five  minutes. 

Dressing. — Take  one  cup  of  beef  bouillon,  add  four  sardelles 
scraped  fine,  the  juice  of  ^  of  a  lemon  and  boil  this  for  ten  minutes. 
Thereafter  add  ^  of  a  glass  of  white  wine,  one  teaspoonful  of  corn- 
starch, lastly  the  yolks  of  two  eggs  stirred  in  a  little  water;  then 
strain  and  pour  over  the  dumplings.  Serve  only  in  a  covered 
tureen. 

Gelatin  Cream  (according  to  Mrs.  J.  C.  Hemmeter)  for  Anacidity 
Without  Symptoms  of  Stagnation. — Juice  of  two  oranges  and  one 
lemon  (a  little  flavor  of  vanilla  extract  may  be  added  if  made  for 
the  healthy),  i  of  a  pound  of  sugar;  stir  well  and  then  add  one  pint 
of  cream  and  beat  until  thick.  Dissolve  ^  of  a  box  of  gelatin  in 
^  of  a  pint  of  cold  water ;  heat  very  gradually  until  all  is  thin  and 


284  REST   AND   exercise;    OF   THE    STOMACH. 

dissolved.     When  cool  add  the  cream,  and  beat  until  it  is  stiff.    May 
be  poured  into  a  mold  and  given  any  shape.* 


THE  USE  AND  ABUSE  OF  REST  AND  EXERCISE  FOR  THE 
DIGESTIVE  ORGANS. 

In  this  connection  we  may  consider  rest  and  exercise  before  and 
after  meals  in  reference  to  the  entire  body,  and  rest  and  exercise  as 
applicable  to  the  stomach  and  intestines  only.  Bodily  exercise  in- 
creases metabolism  and  therefore  the  appetite,  and  gives  rise  to  a 
greater  demand  for  food,  but  when  it  is  carried  too  far,  as  in  the 
overtrained  athlete,  fatigue  may  ensue  and  the  appetite  disappear 
entirely.  Concerning  the  frequent  question  whether  one  should  sleep 
after  taking  meals  or  not,  or  take  exercise,  much  diversity  of  opinion 
exists.  The  edict  of  the  Medical  School  of  Salermo  was:  "Post 
coenam  stabis  aut  passus  mille  meabis,"  which  the  Germans  have 
translated  as  follows :  ' '  Nach  dem  Essen  sollst  du  stehn  oder  tausend 
Schritte  gehn"  ("After  eating  thou  shalt  stand  or  walk  1000  steps"). 
This  question  is  not  easy  to  decide  either  way,  for  sleep  reduces  the 
peristaltic  energy  of  the  stomach,  and  thereby  reduces  the  rate  of  diges- 
tion. A  healthy  person  during  sleep  is  robbed  of  the  impetus  which 
deep  breathing  imparts  to  the  stomach  by  descent  of  the  diaphragm. 

For  most  digestive  sufferers,  however,  all  bodily  exercise,  even 
moderate  movements  following  immediately  on  large  meals,  con- 
stitutes more  or  less  of  a  torment.  In  all  conditions  of  gastric  atony 
and  myasthenia  bodily  rest  is  indispensable,  because  the  stomach 
empties  itself  easier  in  the  reclining  position.  Excepting  in  condi- 
tions of  pronounced  obesity  and  arteriosclerosis,  I  generally  permit 
an  hour  of  sleep  after  the  larger  meals  in  all  dyspeptic  diseases. 
Blood  pressure  is  increased  during  the  digestive  act,  and  for  that 
reason  sleep  in  a  horizontal  position  is  preferably  avoided  in  the  two 
conditions  which  I  have  excluded.  Physical  exertion,  bathing,  or 
training  immediately  after  meals  is  not  to  be  advised,  because  it 
may  exert  undue  pressure  upon  the  stomach,  and  divert  the  blood 
which  this  organ  requires  to  the  overactive  muscles.  Reading  or 
writing  after  meals  may  be  harmful  for  three  reasons: 

I.  Because  it  compels  a  wrong  position  of  the  body,  inclining  it 
too  much  forward. 

*The  author  is  greatly  indebted  to  Mrs.  J.  C.  Hemmeter  for  compiling  and  testing 
many  of  the  most  important  recipes  in  the  "  Dietetic  Kitchen." 


THERAPY   OF    REST   AND   EXERCISE.  285 

2.  Because  of  possible  compression  of  the  region  of  the  stomach, 
due  to  cramped  position  or  to  pressing  against  the  edge  of  the  table. 

3.  Because  of  mental  exertion. 

All  psychic  or  emotional  excitement  immediately  before,  during, 
or  after  meals  is  harmful,  and  it  is  best  not  to  eat  at  all,  if  the  mind 
is  occupied  with  some  distressing  thought.  All  gastric  sufferers  in 
whom  neurasthenia  is  a  factor  should  rest  after  meals,  and  those  with 
pronounced  neurasthenia  should  be  permitted  to  sleep,  for  during 
sleep  nervous  energy  accumulates  and  this  may  aid  in  restoring  the 
lost  digestive  power.  In  all  patients  with  motor  insufficiency  of 
the  first  degree  I  prefer  to  order  sleep  after  meals.  In  the  second 
and  third  degrees  of  this  mechanical  defect  rest  in  bed  becomes  im- 
perative. All  anatomical  diseases  of  the  stomach  require  rest,  and 
in  ulcer,  cancer,  and  acute  gastritis  rest  is  a  "sine  qua  non." 

Mental  Rest. — A  large  number  of  men  of  high  intellectual  ca- 
st 

pacity  are  gastric  sufferers.  This  comes  from  the  universal  abuse 
of  the  mental  energies  contemporaneous  with  overtaxing  the  diges- 
tive organ.  The  cerebral  rest  during  and  after  meals  is  more  im- 
perative than  muscular  rest.  Dyspeptics  ought  not  to  read  their 
mail  or  papers  before  meals,  lest  some  emotional  news  be  imparted, 
reducing  the  appetite  of  these  impressionable  patients.  Many 
gastric  atonies  are  fundamentally  caused  by  an  overwrought  nervous 
system.  This  one,  almost  universal,  modern,  bad  habit  of  over- 
taxing the  brain  and  nerves  is  a  more  dangerous  and  frequent  cause, 
lying,  unknown  and  unrecognized  at  the  foundation  of  many  in- 
cipient gastric  diseases,  than  all  others  put  together. 

Dietetic  Exercise. — Some  forms  of  gastric  disease  do  not  require 
any  extraordinary  amount  of  rest.  It  is  not  very  easy  to  define, 
exactly,  in  just  which  cases  exercise  of  the  stomach  is  required  (as 
by  administration  of  carefully  adapted  diet),  and  which  cases  require 
comparative  rest.  There  is  a  form  of  chronic  gastritis,  of  very  slow 
progression,  in  which  there  is  a  slow  atrophy  of  the  oxyntic  and 
ferment  cells  in  the  peptic  ducts.  I  have  watched  cases  of  this  type 
off  and  on  for  twelve  years,  and  have  learned  by  experience  that  a 
sparing  diet  and  too  much  rest  favor  the  progress  of  the  atrophy, 
whereas  a  proportionate  amount  of  food  to  keep  up  the  caloric 
equilibrium  will  keep  the  peptic  cells  at  work;  for  work  in  this  case 
means  growth  and  sustenance  to  the  histological  elements  of  the 
gastric  mucosa.  It  is  a  mistake  in  those  cases  to  level  d-own  the  diet 
to  the  digestive  capacity  of  the  stomach.     It  should  rather  be  leveled 


286  DI^T^TIC   GYMNASTICS. 

Up,  until  the  digestion  can  effectually  deal  with  the  amount  of  food 
required  to  maintain  the  nitrogen  balance.  It  would  be  just  as 
fatal  a  mistake  to  treat  such  a  stomach  by  repose  (few  and  small 
meals  requiring  little  digestive  work)  as  it  would  be  to  treat  a  mitral 
regurgitation  with  relaxed  ventricular  walls  by  absolute  repose  and 
exclusion  of  exercise.  The  modern  conception  of  heart  disease 
teaches  that  the  stronger  the  ventricular  wall  can  be  developed,  the 
sooner  we  can  bring  on  a  muscular  hypertrophy,  the  more  effectively 
will  compensation  be  established  and  the  patient  have  comparative 
freedom  from  the  consequences  of  his  valvular  insufficiency  (Schott- 
Nauheim  treatment  for  heart  diseases).  The  forms  of  chronic  gas- 
tritis that  I  refer  to  are  always  associated  with  a  good  motility,  so 
that  there  is  no  stagnation  or  retention  of  food  at  any  time.  In 
purely  nervous  anorexia  the  appetite  can  be  restored  more  effec- 
tively by  feeding;  in  fact,  if  the  disease  is  persistent  and  expresses 
itself  by  absolute  refusal  of  food,  it  had  best  be  treated  by  forced 
feeding.  (See  p.  192.)  In  hyperesthesia  and  achylia  gastrica 
dietetic  gymnastics,  when  scientifically  employed  in  the  manner 
described,  are  sometimes  more  beneficial  than  indiscriminate  rest. 
In  all  cases  where  the  tonicity  of  the  gastric  muscularis  is  reduced, 
and  in  cases  of  gastroptosis  and  vertical  position  of  the  stomach 
the  meals  should  be  small  in  quantity  and  all  bodily  movements 
after  the  meals  must  be  avoided.  Kussmaul  (S.  Fleiner,  "Samml. 
klin.  Vortr.,"  Neue  Folge,  No.  103)  has  called  attention  to  the  fact  that 
large  meals  and  abundant  ingestion  of  liquids,  when  such  abnormali- 
ties of  position  and  size  of  the  stomach  exist,  may  cause  a  transient 
mechanical  obstruction  of  the  duodenum.  This  occurs  particularly  if 
exercise  is  taken  after  the  meals  and  the  body  kept  in  an  erect  position, 
which  causes  a  stretching  and  dragging  of  the  greater  curvature.  The 
heavily  loaded  pyloric  portion  of  the  stomach  sinks  and  drags  along 
the  movable  first  portion  of  the  duodenum,  but  at  the  place  where 
the  duodenum  is  rigidly  fixed  to  the  spinal  column  the  bowel  becomes 
kinked  off.     (See  Anatomy  of  Duodenum,  p.  39.) 

Therefore,  in  all  forms  of  dilatation  and  abnormal  positions  of  the 
stomach,  physical  rest  of  the  body  after  meals,  and  as  much  physiologi- 
cal rest  of  the  stomach  as  can  be  consistently  given,  is  imperative.* 

*The  value  of  rest  to  the  stomach  and  rest  to  the  body  in  diseases  of  the  digestive 
organs  is  forcibly  set  forth  in  a  contribution  by  Dr.  C.  D.  Spivak  ("  Rest — A  Neglected 
Factor  in  the  Treatment  of  Gastro-intestinal  Disorder,"  "  The  Journal  of  the  American 
Medical  Association,"  July  30,  1897). 


AMERICANS  EAT  TOO  MUCH.  287 

The  most  explicit  recent  exposition  of  the  physiological  action 
of  rest  to  the  digestive  organs  and  the  prolonged  substitution  of 
exclusive  rectal  alimentation  for  gastric  alimentation,  is  found  in 
a  book,  by  Dr.  A.  P.  Gros  ("Traitement  de  Certaines  Maladies  de 
L'Estomac  par  la  Cure  de  Repos  Ahsolu  et  Prolonge  de  L'Estomac 
Avec  Alimentation  Rectale  Exclusive,"  Paris,  1898).  This  valuable 
book  contains  a  complete  history  of  rectal  feeding  for  the  treatment 
of  gastric  diseases;  the  technics  and  the  indications  for  such  treat- 
ment and  an  exhaustive  bibliography  of  the  subject  extending  over 
nine  pages.  Dr.  Gros  has  employed  this  rest  treatment  not  only  in 
ulcer  of  the  stomach  with  and  without'  hematemesis,  but  also  in 
hypersecretion,  in  hyperacidity  of  long  standing,  in  gastric  catarrh 
with  nervous  anorexia,  in  the  vomiting  of  pregnancy,  and  in  sten- 
oses of  the  pylorus  of  diverse  origin. 

From  a  great  many  observations  which  I  have  made  on  persons 
living  at  hotels,  etc.,  I  have  concluded,  by  approximate  determina- 
tion of  the  amount  of  calories  contained  in  their  daily  food,  that 
the  average  American  in  the  better  classes  of  life  eats  entirely  too 
much.  Of  course,  it  was  possible  to  get  at  the  caloric  value  of  the 
food  only  approximately,  but  allowing  the  widest  margin  for  possible 
sources  of  error,  I  found  that  the  average  number  of  calories  rep- 
resented in  the  food  taken  was  four  thousand  and  forty  per  day 
for  the  average  adult  observed.  This,  of  course,  represents  only 
the  classes  of  individuals  who  can  live  at  hotels  of  the  better  standard. 
As  the -amount  of  caloric  energy  required  for  a  man  of  moderate 
muscular  work  is  only  thirty-five  hundred,  the  excess  of  food  taken 
is  very  evident.  When  sickness  comes  on,  the  common  error  is 
frequently  made  to  introduce  more  food  if  possible  than  in  health, 
on  the  supposition  that  the  weakened  body  requires  strengthening. 
This  excess  of  good  food  and  wine  in  our  modern  treatment  of  disease 
is  as  pernicious  as  the  bleeding,  vomiting,  purging,  and  sweating  of 
our  medical  ancestors. 

In  an  interesting  little  book,  by  Dr.  Dewey,  of  Meadville,  Pa., 
entitled  "The  True  Science  of  Living"  (Hemy  Bill  Publishing  Com- 
pany, London,  1895),  it  is  advised  that  temporary  complete  starva- 
tion until  there  is  once  more  a  healthy  appetite  is  the  best  cure  for 
a  host  of  dyspepsias,  debilities,  bodily  and  mental  depressions, 
headaches,  etc.,  and  that  for  similar  less  severe  disturbances  of 
nutrition  the  great  remedy  is  to  leave  out  the  breakfast,  so  as  to 
give  the  stomach  a  long  rest  of  sixteen  hours  or  more,  with  the  object 


2  88  TWO    MEALS    A    DAY. 

of  allowing  it  to  recuperate  and  accumulate  secretory  energy"  after 
the  last  meal  of  the  previous  day.  One  can  not  fail  to  be  impressed 
with  the  force  of  Dr.  Dewey's  logic  and  the  correctness  of  his  main 
contention.  I  have  frequently  put  this  matter  to  a  test  in  private 
practice,  but  instead  of  omitting  the  breakfast  I  advise  excluding 
the  supper.  The  breakfast  is  taken  at  8  a.  m.  and  the  dinner  at  2 
p.  M.  This  was  preferred  because  a  large  number  of  my  patients 
were  hard-worked  business  men  and  it  was  considered  inexpedient 
to  permit  them  to  go  the  entire  morning  on  an  empty  stomach. 
Six  hours  after  the  dinner,  between  8  and  9  P.M.,  I  order  the  stomach 
thoroughly  washed  out,  and  the  patient  retires  on  a  perfectly  empty 
clean  stomach,  and  the  organ  is  given  twelve  hours  of  absolute  rest 
to  store  up  its  physiological  energy. 

Curiouslv  enough,  the  quantity  of  food  taken,  when  only  two 
meals  a  dav  are  allowed  in  this  manner,  is  often  somewhat  increased 
bevond  the  amount  which  was  hitherto  taken  in  three  meals.  Di- 
gestion is  more  perfect,  the  appetite  is  keener,  nutrition  is  stimulated. 
On  the  recommendation  of  Alexander  Haig  ("Uric  Acid  as  a  Causa- 
tion of  Disease,"  fourth  edition,  London,  1897,  p.  628),  who  found 
this  plan  a  most  powerful  stimulant  to  digestion  and  nutrition,  I 
made  a  thorough  trial  of  Dr.  Dewey's  suggestion  on  my  own  person, 
with  the  result  that  at  present  I  still  carr\-  out  the  two-meal-per- 
day  plan. 

Resting  the  stomach  will  enable  it  to  do  much  better  work  and 
leads  to  a  keen  hunger  otherwise  unknown.  Haig  concludes  that 
if  anything  will  demonstrate  the  insane  folly  of  stuflfing  a  dyspeptic 
stomach  with  fresh  food  every  three  or  four  hours,  an  experience 
of  this  kind  ought  to  do  it,  and  I  can  confirm  his  suggestion  that 
almost  the  only  danger  attendant  on  taking  two  meals  a  day,  in 
place  of  three  or  four,  is  that  of  overeating.  The  two-meal-a-day 
plan  is  one  of  the  most  effective  means  of  combating  intestinal  flatus 
which  arises  from  undigested  residues.  It  is  quite  possible  for  a 
man  to  be  better  nourished  on  a  little  food  eaten  slowly  and  well 
mixed  with  saliva  than  on  a  great  deal  of  food  eaten  very  quickly. 
I  have  seen  a  number  of  cases  where  persons  seemed  undernourished 
on  three  to  four  meals  a  day  who  gained  weight  and  showed  a  better 
appetite,  and  no  undigestible  residues  in  the  stools,  when  but  two 
meals  a  day  were  allowed.  It  is  quite  conceivable  that  persons  may 
be  in  a  state  of  starv^ation,  not  from  any  want  of  food,  but  from  the 
fact  that  the  digestive  capacity  is  constantly  overpowered  by  excess 


DIETETICS   OF   ALCOHOL.  2«9 

of  food.  The  so-called  uric-acid-free  diet,  which  Haig  urgently 
recommends  in  form  of  a  diet  consisting  almost  exclusively  of  sub- 
stances derived  from  the  vegetable  kingdom,  is,  in  my  experience, 
not  universally  applicable  to  digestive  diseases.  It  should,  however, 
be  more  employed  than  it  has  been  hitherto,  particularly  in  those 
stomach  affections  associated  with  hyperacidity.  In  the  beginning 
no  surprising  beneficial  results  may  be  evident,  but  the  success  of 
the  treatment  depends  on  the  persistency  with  which  it  is  carried  out. 
Haig  permits  the  use  of  milk,  butter,  and  cheese,  but  forbids  meats 
of  any  kind. 


CHAPTER  111. 

THE  DIETETICS  OF  ALCOHOL  AND  ALCOHOLIC 
BEVERAGES. 

The  literature  on  the  subject  of  the  physiological  action  and  the 
metabolic  and  dietetic  influences  of  alcohol  is  very  extensive.  Its  ab- 
normal growth  appears  to  those  who  make  an  effort  to  keep  abreast  of 
the  progress  and  advancement  of  experimental  therapeutics,  out  of  all 
proportion  to  any  real  increase  in  our  knowledge  of  the  subject.  We 
are  directly  concerned  only  with  the  (i)  value  (if  any)  of  alcohol  as  a 
food;  (2)  as  a  tonic  and  stimulant;  (3)  its  effects  upon  the  digestive 
functions.  The  use  of  alcohol  in  any  shape  is  wholly  unnecessary  for 
the  use  of  the  human  organism  in  health.  A  large  number  of  persons 
prolong  their  lives  by  total  abstinence.  This  should  be  so  stated  with 
emphasis,  since  there  are  so  many  who  imagine  it  is  indispensable, 
when  in  reality  they  are  injured  by  it.  The  effects  of  alcohol  on  other 
organs  than  the  stomach  are  very  important ;  but  we  must  refer  to 
the  literature  on  the  special  experiments :  For  the  influence  of  CjHeO 
on  the  heart,  see  J.  C.  Hemmeter,  "The  Comparative  Physiological 
Effects  of  the  Ethylic  Alcohol  Series  on  the  Isolated  Mammalian 
Heart"  (in  "Studies  from  the  Biological  Laboratory  of  the  Johns 
Hopkins  University,"  vol.  iv,  No.  5).  On  the  value  of  alcohol  on 
various  body  functions,  see  Oilman  Thompson,  "Dietetics,"  pages 
205  to  232;  Binz,  "  Pharmakologie " ;  Schmiedeberg,  "Arzneimittel- 
lehre."     The  literature  on  the  effect  of  alcohol  on  the  functions  of  the 


290  DIETETICS   OE   ALCOHOLIC   BEVERAGES. 

Stomach  can  be  found  in  the  text-books  of  Riegel,  Boas,  Ewald, 
Wegele,  Penzoldt  (vol.  iv  of  "Handbuch  d.  Therapie"),  Munk,  and 
Uffelmann.  The  Hterature  is  too  great  and  the  results  are  too  un- 
certain to  permit  of  any  resume  to  be  given  here.  The  question 
arises,  "Why  do  we  give  alcohol  in  gastric  therapeutics?  Is  it  a  food 
or  merely  a  stimulant?  In  doses  taken  ordinarily  with  the  more 
common  beverages  does  it  facilitate  or  retard  digestion?"  Most  of 
the  text-books  mentioned  take  the  stand  that  as  alcohol  is  oxidized 
in  the  body  it  furnishes  a  considerable  amount  of  energy. 

The  question  whether  alcohol  is  a  true  food-stuff,  capable  of 
serving  as  a  direct  source  of  energy  and  of  replacing  a  corresponding 
amount  of  fats  or  of  carbohydrates  in  the  daily  diet,  is  a  matter  of 
controversy.  Reichert  ("Therapeutic  Gazette,"  Feb.  15,  1890)  con- 
cludes that  moderate  doses  of  alcohol  do  not  affect  the  total  amount 
of  heat  produced  in  the  body  of  a  dog.  As  it  is  nearly  completely 
oxidized  in  the  body,  and  gives  off  considerable  heat  in  the  process, 
the  fact  that  the  total  heat  production  remains  unaltered  indicates 
that  the  oxidation  of  alcohol  protects  an  isodynamic  amount  of  food- 
materials  in  the  body  from  consumption,  thus  acting  as  a  food-stuff 
capable  of  replacing  other  elements  of  the  food.  Opposed  diametric- 
ally to  these  results  are  those  of  Miura  ("Zeitschr.  f.  klin.  Medicin," 
1892,  vol.  XX,  p.  137),  whose  observations  were  made  on  his  own 
metabolism,  after  he  had  brought  himself  into  a  condition  of  nitrogen 
equilibrium  upon  a  mixed  diet.  Then  for  a  time  a  portion  of  the 
carbohydrates  was  omitted,  and  its  place  substituted  by  an  isody- 
namic amount  of  alcohol.  The  result  was  a  loss  of  proteid  from  the 
body,  proving  that  the  alcohol  had  not  protected  the  proteid  tissue 
as  it  should  have  done  if  it  acts  as  a  food.  In  a  third  period  the  old 
diet  was  resumed,  and  after  nitrogen  equilibrium  had  again  been 
established,  the  same  proportion  of  carbohydrates  was  omitted  from 
the  diet,  but  alcohol  was  not  substituted. 

When  the  diet  was  poor  in  proteid,  it  was  found  that  less  proteid 
was  lost  from  the  body  when  alcohol  was  omitted  than  when  it 
was  used,  indicating  that  so  far  from  protecting  the  tissues  of  the 
body  by  its  oxidation,  the  alcohol  exercised  a  directly  injurious 
effect  upon  proteid  consumption.  Recent  experimental  investiga- 
tions (Rosemann,  ' '  Ueber  d.  Einfluss  des  Alkohols  auf  den  mensch- 
lichen  Stoffwechsel, "  "Zeitschr.  f.  Diatet.  u.  physikal.  Therapie," 
von  Leyden  u.  Goldscheider,  Bd.  i,  p.  138)  confirm  Miura's  results, 
namelv,  that  alcohol  is  no  proteid  saver,  but  protects  the  fats  from 


EFFECT  OF  ALCOHOL  ON  METABOLISM.  29I 

consumption.  Further  researches  will  have  to  show  whether  and 
how  it  protects  the  oxidation  of  non-nitrogenous  constituents  of  the 
body — the  fats. 

Professor  W.  O.  At  water,  from  experiments  on  the  effect  of  alco- 
hol on  metabolism,  conducted  in  a  thoroughly  scientific  and  sys- 
tematic manner  at  the  Wesleyan  University,  concludes: 

1.  The  alcohol  is  oxidized — that  is,  burned — as  completely  as 
bread,  meat,  or  any  other  food. 

2.  In  the  oxidation  all  the  potential  energy  of  the  alcohol  was 
transformed  into  heat  and  muscular  power.  In  other  words,  the 
body  made  the  same  use  of  the  energy  of  the  alcohol  as  of  that  of 
sugar,  starch,  and  other  ordinary  food  materials. 

3.  The  alcohol  protected  the  material  of  the  body  from  consump- 
tion just  as  effectively  as  the  corresponding  amounts  of  sugar  and 

a    starch — that  is  to  say,  whether  the  body  was  at  rest  or  at  work,  it 
held  its  own  just  as  well  with  the  one  as  with  the  other. 

According  to  Atwater,  alcohol  is  not  a  tissue  builder,  but  it  can 
and  does  serve  as  fuel.  The  amount  used  in  his  experiments  per 
day  was  equal  to  about  2^  ounces  of  absolute  alcohol — about  as 
much  as  would  be  contained  in  five  or  six  ounces  of  whisky  or  in 
a  quart  of  claret  or  Rhine  wine.  (Extract  from  "Report  to  Middle- 
town  (Conn.)  Scientific  Assoc";  the  experiments  have  not  yet  been 
published.) 

It  is  emphasized  that  alcohol  is  not  a  desirable  food  for  common 
use;  for  in  saving  the  non-nitrogenous  bodies  (the  fats)  from  con- 
sumption— an  observation  which  agrees  well  with  the  practical  ex- 
periences concerning  the  habitual  use  of  alcohol — it  is  very  probable 
that  alcohol  acts  as  a  weak  protoplasmic  poison.  Miura  {loc.  cit.) 
has  already  suggested  such  an  influence;  also  Romeyn  (see  Maly's 
"Yahresbericht  d.  Thierchemie, "  1887,  p.  400),  Stammreich  ("Inaug. 
Dissert.,"  Berlin,  91),  and  A.  Schmidt  ("Centralbl.  f.  d.  Med.  Wiss.," 
1875,  No.  23).  The  work  of  these  four  experimenters  showed  an 
increased  albumin  breakdown,  which  in  Miura  and  Stammreich's 
observations  continued  for  two  days  after  the  use  of  alcohol  had  been 
stopped.  The  results  of  Atwater  do  not  support  the  assumption 
that  alcohol  may  be  used  as  a  food ;  they  indicate  that  it  protects  the 
oxidation  of  the  fats.  Saving  the  fats  from  consumption,  even  if  it 
could  be  accomplished  without  injurious  collateral  effects,  is,  from 
a  therapeutic  standpoint,  only  very  rarely  desirable  (emaciation, 
tuberculosis).     But  if  it  is  accompanied  by  increased  destruction  of 


292  DIETETICS    OF    ALCOHOLIC    BEVERAGES. 

the  proteids  of  the  body,  then  alcohol  is  not  a  dietetic  aid  for  the 
advancement  of  nutrition. 

Therapeutically,  there  is  still  conceded  to  alcohol  a  stimulating  and 
an  antipyretic  influence. 

Concerning  the  effects  of  moderate  amounts  of  alcohol  on  diges- 
tion b)^  pepsin-hydrochloric  acid,  and  on  salivary  and  pancreatic 
digestion,  we  believe  the  following  abstract  of  Chittenden  and  Men- 
del's experiments  ("American  Journal  of  Medical  Sciences,"  January 
to  April,  1896)  to  be  a  clear  representation  of  this  matter: 

One  can  not  define  with  mathematical  exactness  the  action  of  a 
given  percentage  of  absolute  alcohol  on  pepsin  proteolysis,  since 
variation  in  the  attendant  conditions,  i.  e.,  the  relative  amounts  of 
pepsin,  acid,  and  proteid,  together  with  the  period  of  digestion,  the 
digestibility  of  the  particular  proteid,  etc.,  are  prone  to  modify  the 
final  result.  Thus,  with  a  weak  gastric  juice,  where  the  amount  of 
ferment  present  is  small,  and  digestive  action  consequently  slow, 
or  where  the  proteid  material  used  is  difficult  of  digestion,  the  retard- 
ing effect  of  a  given  percentage  of  alcohol  is  far  greater  than  when 
the  digestive  fluid  is  more  active;  that  is,  when  it  contains  more 
pepsin.  Further,  this  difference  of  action  is  more  pronounced  the 
larger  the  percentage  of  alcohol  present.  The  following  general  con- 
clusions were  drawn  from  artificial  digestive  mixtures. 

First,  It  is  plainly  manifest  that  in  the  presence  of  small  amounts 
of  alcohol  (one  to  two  per  cent,  of  absolute  alcohol)  gastric  digestion 
may  proceed  as  well  or  even  better  than  under  normal  circumstances. 
In  fact,  many  of  their  experiments  show  a  slight  increase  in  digestive 
power  when  the  mixture  contained  one  or  two  per  cent,  of  absolute 
alcohol.  This  increased  digestive  action,  though  slight,  occurred  too 
frequently  to  be  the  result  of  mere  accident,  and  apparently  indicates 
a  tendency  for  alcohol,  when  present  in  small  quantity,  to  slightly  in- 
crease the  digestive  action  of  pepsin-hydrochloric  acid;  or,  in  other 
words,  to  stimulate  the  ferment  so  that  it  can  accomplish  somewhat 
more  than  it  otherwise  could  do.  As  the  percentage  of  alcohol  is 
raised,  retardation  or  inhibition  becomes  more  noticeable,  although 
ordinarily  it  is  not  very  pronounced  until  the  digestive  mixture  con- 
tains five  to  ten  per  cent,  of  absolute  alcohol.  With  15  to  18  per 
cent,  of  absolute  alcohol  digestive  action  may  be  reduced  one-quarter, 
or  even  one-third;  the  exact  amount  of  retardation,  however,  being 
especially  dependent  upon  the  activity"  of  the  gastric  juice  and  upon 
the  natural  digestibility  of  the  proteid  material.     It  is  to  be  remem- 


ACTION    OF    AIvCOHOL    ON    PANCREATIC    DIGESTION.  293 

bered,  however,  that  18  per  cent,  of  absolute  alcohol  would  be  equiva- 
lent to  36  per  cent,  of  proof-spirit;  so  that,  if  we  could  assume  the 
contents  of  the  human  stomach  at  a  given  period  to  contain  one-third 
proof-spirit,  it  might  perhaps  be  considered  that  digestive  action 
would  be  retarded  to  the  extent  of  25  to  35  per  cent.,  provided  the 
gastric  juice  present  in  the  stomach  was  of  fair  strength  and  the 
proteid  matter  of  ordinary  digestibility.  Such  percentages  of  proof- 
spirit,  however,  are  not  likely  to  be  long  present  in  the  stomach, 
and  it  is  perhaps  idle  to  speculate  on  such  hypothetical  cases.  We 
may  in  this  connection,  however,  again  emphasize  the  fact  that  the 
stronger  the  gastric  juice  and  the  more  digestible  the  proteid  food 
undergoing  digestion,  the  less  retardation  will  a  given  percentage  of 
alcohol  produce;  while,  on  the  other  hand,  the  weaker  the  gastric 
juice  and  the  more  indigestible  the  proteid,  the  greater  will  be  the 
inhibition  caused  by  a  given  percentage  of  alcohol.  In  other  words, 
those  variations  which  must  naturally  exist  in  the  stomach  contents 
of  different  individuals,  both  in  health  and  disease,  will  lead  to 
different  degrees  of  retardation  in  the  presence  of  given  percentages 
of  absolute  alcohol.  It  would,  therefore,  be  unwise  to  make  a  general 
specific  statement  regarding  the  action  of  a  given  percentage  of  alco- 
hol. Under  definite  conditions,  however,  as  Chittenden's  experi- 
ments plainly  show,  the  presence  of  a  definite  amount  of  alcohol 
always  leads  to  essentially  the  same  results. 

In  order  to  prevent  any  misinterpretation  of  these  results,  we 
would  again  call  attention  to  the  fact  that  we  are  dealing  here  with 
only  one  of  the  four  questions  that  need  to  be  answered  before  we 
can  hope  to  fully  understand  the  influence  of  alcohol  on  gastric 
digestion  as  a  whole.  Thus,  the  results  afford  plain  evidence  of  the 
influence  of  alcohol  on  the  digestive  or  solvent  power  of  the  gastric 
juice ;  but  we  should  not  be  justified  in  arguing  that  exactly  the  same 
results  would  follow  from  the  introduction  of  alcohol  into  the  living 
stomach.  The  action  of  a  given  percentage  of  alcohol  on  proteolysis 
alone  would  be  essentially  the  same  in  the  stomach  as  in  a  beaker, 
provided  the  alcohol  was  not  absorbed  into  the  blood  and  thus  re- 
moved from  contact  with  the  digestive  mixture,  and  provided  it  did 
not  exert  any  influence  on  the  character  of  the  gastric  juice  secreted. 
But  it  is  easily  conceivable  that  a  percentage  of  alcohol  which  does  not 
interfere  with  solution  of  the  proteid  food-stuffs  may  so  modify  the 
amount  or  character  of  the  secretion  that  digestion  might  be  greatly 
stimulated   or  greatly   retarded.     Further,    as   already   stated,    the 


294  DIETE^TICS   OF   ALCOHOLIC   BEVERAGES. 

presence  of  alcohol  in  the  stomach  may  so  affect  absorption  and  peri- 
stalsis that  the  rate  of  digestion  may  be  modified  from  this  cause; 
hence  the  results  above  recorded  are  to  be  used  only  in  drawing  con- 
clusions as  to  the  effect  of  various  percentages  of  alcohol  on  the  purely 
chemical  process  of  gastric  digestion,  i.  e.,  on  pepsin-proteolysis. 

In  conclusion,  it  is  to  be  noted  that  Chittenden's  results  are  more 
or  less  in  accord  with  what  has  been  previously  published  concerning 
the  action  of  alcohol  on  gastric  digestion.  Thus,  Bikfalvi  found,  in 
artificial  digestive  experiments,  that  alcohol,  even  in  small  quantities, 
retards  normal  gastric  digestion.  Klikowicz  found  that  the  presence 
of  five  per  cent,  of  alcohol  in  the  digestion  of  egg-  and  serum-albumin 
led  to  somewhat  variable  results,  although,  as  a  rule,  there  was  an 
indication  of  a  slight  stimulation  of  proteolytic  action.  In  the 
presence  of  ten  per  cent,  of  alcohol  there  was  always  marked  retarda- 
tion, while  fifteen,  twenty,  and  thirty  per  cent,  of  alcohol  checked 
digestion  to  a  marked  degree. 

Roberts  found,  by  artificial-digestion  experiments,  that  in  the 
presence  of  less  than  ten  per  cent,  of  proof-spirit  there  was  no  ap- 
preciable retardation.  With  ten  per  cent.,  retardation  was  only 
barely  detectable.  With  twenty  per  cent,  there  was  quite  distinct 
but  still  only  a  slight  retardation.  Above  this  point,  however,  the 
inhibitory  effect  of  alcohol  increased  rapidly.  (Refer  to  the  tables 
of  Roberts  at  the  end  of  this  chapter.)  That  the  action  of  a  digestive 
ferment  may  be  both  stimulated  and  retarded  by  the  same  substance, 
according  to  the  quantity  present,  has  been  already  demonstrated; 
hence  there  is  no  inconsistency  in  the  above  results  with  alcohol. 
The  same  action  has  likewise  been  observed  with  yeast-cells. 

Action  of  Alcohol  on  Pancreatic  Digestion. — In  view  of  the 
position  which  pancreatic  digestion  occupies  in  the  digestive  process, 
it  is  readily  seen  that  it  is  more  desirable  to  ascertain  the  influence 
of  small  quantities  of  alcoholic  liquors  than  large  amounts,  since 
absorption  must  naturally  lead  to  a  decided  diminution  of  alcohol 
before  it  can  normally  become  mixed  with  the  pancreatic  juice  and 
partially  digested  food-material  in  the  small  intestine.  Hence,  more 
stress  was,  as  a  rule,  laid  upon  the  influence  of  small  percentages  of 
the  various  fluids  experimented  with,  and  only  occasionally  the 
action  of  large  quantities  was  tried. 

The  results  with  absolute  alcohol  indicate  that  the  proteolytic 
ferment  of  the  pancreatic  juice  is  more  sensitive  to  absolute  alcohol 
than  the  ferment  of  the  gastric  juice.     Retardation  of  digestive 


EFFECT  OF  ALCOHOE  ON  ABSORPTION.  295 

action  is  more  pronounced,  even  with  small  amounts  of  alcohol. 
Further,  as  in  the  case  with  pepsin,  the  weaker  the  digestive  powers 
of  the  pancreatic  juice,  the  greater  the  retarding  action  of  absolute 
alcohol.  When  the  amount  of  alcohol  present  in  the  digesting 
mixture  is  less  than  one  per  cent,  the  retardation  of  the  digestive 
action  is  very  slight,  provided  the  ferment  is  fairly  vigorous  in  its 
action. 

Action  of  Alcohol  on  Salivary  Digestion. — In  the  first  set  of 
experiments  on  salivary  digestion  Chittenden  determined  the  time 
it  took  to  reach  the  achromic  point.  By  this  method  he  found  that 
absolute  alcohol  has  very  little  influence  upon  the  amylolytic  or 
starch-digesting  power  of  neutral  saliva.  Only  when  the  saliva, 
added  to  the  digestive  mixture,  is  diluted  in  the  proportion  of  i :  30, 
does  the  presence  of  even  ten  per  cent,  of  alcohol  have  any  measurable 
influence,  and  then  only  to  retard  the  appearance  of  the  achromic 
point  two  minutes.  As  this  percentage  of  absolute  alcohol  is  equal 
to  at  least  twenty  per  cent,  of  proof -spirit,  it  follows  that  pure  alcohol 
free  from  admixture  is  practically  without  influence  upon  the  diges- 
tion of  farinaceous  food  by  the  saliva. 

By  the  second  method,  which  was  to  determine  the  amount  of 
maltose  formed,  he  found  that  small  amounts  of  absolute  alcohol 
may  actually  cause  an  increased  formation  of  maltose.  On  the  other 
hand,  the  presence  of  ten  or  fifteen  per  cent,  of  absolute  alcohol  leads 
to  a  distinct  retardation  in  the  formation  of  sugar,  although  the  in- 
hibition is  not  very  great  considering  the  amount  of  alcohol  present. 
This  retardation  of  the  secondary  action  of  the  ferment  is  perhaps 
suggested  by  the  slight  delay  in  the  appearance  of  the  achromic  point 
in  the  presence  of  ten  per  cent,  of  absolute  alcohol. 

Effect  of  Alcohol  on  Gastric  Peristalsis. — We  have  personally 
made  a  number  of  observations  concerning  this  special  point  on 
three  healthy  students  with  normal  stomachs  by  means  of  our  method 
of  graphically  registering  the  gastric  peristalsis  on  the  kymographion 
("New  York  Med.  Journal,"  June  22,  1895).  These  students  were 
teetotalers,  and  to  exclude  the  influence  of  suggestion  the  alcohol 
was  poured  into  the  stomach,  diluted,  through  a  tube,  and  sometimes 
water  was  used  in  place  of  alcohol.  The  subject  was  at  no  time 
aware  of  what  was  being  used.  It  was  found  that  alcohol,  when 
contained  in  gastric  contents  up  to  six  per  cent.,  exerts  no  appreciable 
effect  on  the  motility  one  way  or  the  other;  but  beyond  this  the 
peristalsis  begins  to  show  evidence  of  impairment. 


296  DIETETICS   OF   ALCOHOLIC   BEVERAGES. 

The  presence  of  twenty  to  twenty-five  per  cent,  of  alcohol  leads 
to  a  very  distinct  retardation  and  reduction  of  the  tonicity  in  the 
gastric  movements,  which  seems  to  last  in  its  effects  from  two  to  three 
hours.  Even  after  the  alcohol  is  thoroughly  washed  out  of  the 
stomach  the  peristalsis  continues  to  be  retarded. 

In  dogs  the  identical  results  were  obtained,  except  that  at  five  to 
six  per  cent,  a  short  period  of  peristaltic  unrest  was  observed  before 
the  marked  inhibition  developed.  The  inhibition  of  the  peristalsis 
when  the  gastric  contents  contain  twenty  to  twenty-five  per  cent, 
of  alcohol  occurs  quite  regularly,  and  is  not  the  result  of  mere  acci- 
dent. It  is  probably  due  to  a  direct  poisoning  effect  on  the  muscu- 
laris,  similar  to  the  poisoning  effect  on  the  heart-muscle  observed 
by  us  (Hemmeter,  "Studies  from  the  Biological  Laboratory,"  loc. 
cit.).  This  amount  of  alcohol  must  be  in  the  organ  at  least  ten 
minutes  before  the  peristaltic  inhibition  sets  in. 

Effect  on  Absorption. — The  effect  of  alcohol  on  the  rate  of  ab- 
sorption from  the  stomach  is  a  different  question  from  the  absorba- 
bility of  the  substance  itself.  There  is  a  general  unanimity  that, 
owing  to  its  rapid  diffusibility,  alcohol  is  promptly  absorbed  from 
mucous  surfaces.  At  the  same  time  the  experimxcnts  of  von  Mehring 
suggest  that  the  absorption  of  substances  soluble  in  alcohol  ma}^ 
be  facilitated  by  the  latter;  for  example,  that  peptone  or  maltose 
taken  in  alcohol  may  be  absorbed  more  rapidly  than  when  taken 
in  water.  Exact  experimental  facts  concerning  this  matter  are 
wanting. 

In  large  doses  alcohol  hinders  absorption  by  the  direct  damage  it 
does  to  the  cylindrical  surface  epithelium. 

Among  gastro-enterologists  the  impression  prevails  that  alcohol 
and  alcoholic  beverages  are  capable  of  promoting  the  appetite;  and 
probably  for  this  purpose  and  for  its  stimulating  effect  we  are  justi- 
fied in  giving  it.  Summing  up  the  physiological  action,  so  far  as 
we  are  concerned,  it  may  be  said:  (i)  The  effect  of  moderate  doses 
of  alcohol  on  metabolism  is  that  it  not  only  fails  to  protect  proteid 
oxidation,  but  actually  increases  it.  Oxidation  of  fat  is  probably 
inhibited.  (2)  That  on  pepsin  hydrochloric  acid  it  acts  favorably  in 
quantities  equal  to  one  to  two  per  cent,  of  absolute  CzHeO,  but 
beyond  that  it  gradually  inhibits  this  action.  (3)  On  pancreatic 
digestion  it  acts  unfavorably.  (4)  On  salivarj^  digestion  it  acts 
favorably,  increasing  the  formation  of  maltose  when  present  in 
amounts  not  exceeding  five  per  cent.      (5)  On  the  peristalsis  it  has 


EFFECT    OF    MAlvT   LIQUORS    ON    GASTRIC    DIGESTION.  297 

no  influence  until  the  amount  exceeds  six  per  cent.,  when  it  begins 
to  inhibit  the  motihty.  (6)  Its  effect  on  the  rate  of  absorption  is 
unknown. 

In  pathological  conditions  the  eifects  of  alcohol  are  undeniably 
dift'erent,  its  stimulating  and  temperature-depressing  influence  mak- 
ing it  of  value  in  continued  fevers.  In  pathological  cases,  wherever 
the  amount  of  free  HCl  is  altered,  either  in  hyperchylia  or  achylia 
gastrica,  Chittenden's  deductions  do  not  hold  good.  In  hypochylia, 
or  subacidity,  alcohol  may  be  of  some  service  in  stimulating  the 
mucosa  to  more  prolific  secretion,  but  in  hyperchylia  it  irritates 
the  already  very  much  excited  gland-cells  still  further.  In  achylia 
with  entire  absence  of  secretion,  digestion  is  considerably  reduced 
■  by  alcohol.  Speaking  generally,  alcohol  might  be  dispensed  with 
as  a  therapeutic  and  dietetic  agent  if  it  were  not  for  its  appetizing, 
stimulating,  and  antipyretic  qualities.  In  hyperacidity  and  hyper- 
secretion, in  ulcer  and  all  chronic  affections  with  augmented  secre- 
tion, alcohol  is  contraindicated.  In  atonic  stomachs  with  retention 
and  stagnation  of  contents  and  pronounced  impairment  of  motility 
alcohol,  in  our  experience,  acts  as  a  poison.  Symptoms  of  vertigo, 
nausea,  and  even  tetany  are  directly  traceable  to  the  introduction  of 
whisky  or  wine  under  such  conditions.  In  our  opinion  these  results 
are  brought  about  by  substances  already  existing  in  these  types  of 
stomach  diseases,  which  are  prevented  from  entering  the  circulation 
by  a  protective  action  of  the  gastric  mucosa,  which  does  not  absorb 
them.  The  addition  of  alcohol  renders  these  toxins  absorbable. 
Healthy  stomachs  not  rarely  exhibit  a  certain  adaptation  to  alcohol, 
and,  naturally,  upon  such  organs  the  agent  has  a  different  effect  than 
upon  the  stomach,  of  a  teetotaler. 

Beer  has  a  very  little  therapeutic  utility;  by  reason  of  its  weight 
it  is  contraindicated  in  all  conditions  weakening  the  gastric  wall. 
Riegel  holds  that  it  is  well  to  permit  its  use  in  simple  hyperacidity. 
It  contains  a  certain  amount  of  nutritious  matter,  and  should,  there- 
fore, not  be  forbidden  if  the  patient  craves  it,  provided  the  motor 
power  is  good.  Even  the  absorption  of  less  bulky  wines  is  attended 
by  an  excretion  of  water  into  the  stomach  (von  Mehring,  loc.  cit.), 
which  may  favor  stasis  of  liquids  and  furtherance  of  existing  dilata- 
tion. 

The  following  is  a  table  by  Roberts  ("Lectures  on  Dietetics  and 
Dyspepsia"),  showing  the  effects  of  various  percentages  of  malt 
liquors  on  gastric  digestion: 


dibte;tics  of  ai^coholic  be;verages. 


Proportion  of  Malt  Liquors  in 

Time  in  which  Digestion  was  Completed 
(Normal,  One  Hundred  Minutes). 

THE  Digesting  Mixture. 

Ale, 
Burton. 

Light  English 
Table  Beer. 

Lager  Beer. 

Ten  per  cent., 

Twenty  per  cent., 

Forty  per  cent., 

Sixty  per  cent., 

115  minutes,  .    . 
140        " 
200        " 
Embarrassed,     . 

lOOmmutes,  .    . 

IIS       "         .    • 
140       "          .    . 
180        "         .    . 

100  minutes. 
115        " 
140       " 
180       " 

The  digesting  mixture  contained  two  gm.  of  dried-beef  fiber,  0.15 
per  cent,  of  hydrochloric  acid  (HCl),  and  one  c.c.  of  glycerin,  extract 
of  pepsin,  and  varying  quantities  either  of  wines  or  malt  liquors,  and 
filling  up  to  100  c.c.  with  water. 

The  following  table  gives  the  effects  of  varying  percentages  of 
hock,  claret,  and  champagne  upon  peptic  digestion  (Roberts) : 


Proportion  of  Hock,  Claret,  or 
Champagne  in  the  Digesting 

Time  in  which  Digestion  was  Completed 
(Normal,  One  Hundred  Minutes). 

Mixture. 

Hock. 

Claret. 

Champagne. 

Ten  per  cent.,        ,    .            ... 

100  minutes,  .  '. 

115       "         .    . 
150       "         .    . 
Embarrassed,     . 

100  minutes,  .    . 
140       "         .    . 
180       "          .    . 
Embarrassed,     . 

90  minutes. 

Twenty  per  cent., 

Forty  per  cent., 

Sixty  per  cent., 

100        " 
130        " 
180        " 

In  cases  of  gastric  disease  where  great  general  debility  commands 
liberal  alcoholic  stimulation,  particularly  if  the  gastric  motor  func- 
tion be  impaired,  it  is  best  to  administer  the  stimulant  by  rectal 
enema.  It  may  have  been  observed  that  most  of  the  enemata  have 
provided  for  this  emergency,  and  contain  more  or  less  wine. 

Sir  Wm.  Roberts  points  out  that  in  the  plan  of  the  dietary  of 
the  civilized  races,  arrived  at  slowly,  as  the  result  of  an  immense 
experience,  we  seem  to  detect  two  apparently  contradictory  aims — 
namely,  on  the  one  hand,  to  render  food,  by  preparation  and  cook- 
ing, as  digestible  as  possible ;  and,  on  the  other  hand,  to  control  the 
rate  of  digestion  by  the  use  of  certain  accessory  articles  with  food, 
such  as  alcoholic  beverages.  In  reality  these  objects  are  not  contra- 
dictory, but  cooperative  to  a  beneficial  end.  For,  to  express  the 
problem  in  another  way,  it  may  be  said  that  we  render  food,  by 
preparation,  as  capable  as  possible  of  being  completely  exhausted 
of  its  nutrient  properties;  and,  on  the  other  hand,  to  prevent  this 


lavage;  and  the  gastric  douche.  299 

nutrient  matter  from  being  wastefuUy  hurried  through  the  body  we 
make  use  of  agents  which  abate  the  speed  of  digestion.  This  com- 
bination of  appHances  renders  our  plan  of  feeding  more  elastic,  more 
adaptable  to  variety  of  individual  health  and  constitution,  and  to 
variety  of  external  conditions. 

If  this  view  of  digestive  retardation  in  the  stomach  be  well  founded, 
the  stomach  becomes  in  some  degree  a  storage  organ  for  food — like 
the  crop  of  birds,  the  paunch  of  ruminants,  the  dilatable  cheeks  of 
monkeys,  and  the  pouch  of  the  pelican. 

This  classical  writer  on  dietetics  expresses  himself  similarly  on 
the  importance  of  preparing  the  food  in  such  a  way  that  it  tastes 
good  (Sir  William  Roberts,  loc.  cit.,  "The  Eulogium  of  the  Palate"). 
Even  Bunge,  the  well-known  physiologist,  who  is  a  pronounced  tee- 
totaler, declares  that  we  are  justified  in  the  use  of  any  food  or  drink 
if  for  no  other  reason  but  that  it  gratifies  the  palate,  provided 
it  does  no  harm ;  but  the  substitution  of  harmless  food  and  drink  for 
alcohol  is  strongly  urged. 


CHAPTER  IV. 

LAVAGE  AND  THE  GASTRIC  DOUCHE. 

The  technics  of  lavage — the  indications  for  and  against  it — have 
been  treated  in  the  section  on  the  Stomach-tube.  In  brief,  lavage 
is  indicated  (a)  where  the  exit  of  the  chyme  from  the  stomach  is 
hindered  by  a  mechanical  obstruction,  giving  rise  to  decompositions. 
To  this  class  belong  all  forms  of  dilatation  except  those  depending 
on  simple  atony,  for  here  we  are  not  dealing  with  any  obstruction  to 
the  outflow,  but  with  a  lowering  of  the  peristalsis,  which  is  not 
markedly  benefited  by  lavage.  Dilatations  that  indicate  lavage  are 
those  due  to  cicatricial  stenosis,  or  neoplasm  of  the  pylorus  and 
duodenum,  and  impairment  of  motor  function  in  consequence  of 
carcinoma,  sarcoma,  syphilitic  and  tuberculous  gastritis,  simple 
atrophic  gastritis,  myasthenia,  contractions  caused  by  acids,  alkalies, 
or  other  chemicals.  The  benefit  derived  from  lavage  must  vary  with 
the  stage  at  which  the  treatment  is  undertaken.  In  cases  of  cicatri- 
cial stenosis  of  mild  and  incipient  character  the  dilatations  have  been 


300  LAVAGE    AND   THE    GASTRIC    DOUCHE. 

cured  by  lavage,  probably  because  a  compensatory  hypertrophy  of 
the  musculature,  developing  gradually,  enabled  the  organ  to  expel 
the  chyme.  In  these  gastrectasias  the  stomach,  after  the  systematic 
lavage  treatment,  no  longer  contained  food  and  HCl  in  large  quan- 
tities in  the  morning.  The  stools  and  the  quantity  of  the  urine  be- 
came normal,  and  the  patients  could  tolerate  an  ordinary  diet.  But 
such  cases  must,  even  after  recover}^,  avoid  overloading  the  stomach, 
as  this  has  been  known  to  bring  about  relapse.  The  compensatory 
hypertrophy  of  the  musculature,  although  it  may  last  for  years,  in 
these  cases  is  not  a  permanent  condition,  and  in  oru  experience  often 
gives  way  to  a  subsequent  atrophy  and  return  of  all  the  symptoms 
of  stagnation. 

(b)  The  second  main  indication  is  where  foreign  or  irritating  collec- 
tions are  mixed  with  the  gastric  contents,  w^hich  sooner  or  later  inter- 
fere with  digestion.  These  collections  may  consist  of  abnormally 
augmented  gastric  juice,  of  gastric,  pharyngeal,  and  esophageal 
mucus,  and  of  bile.  In  hypersecretion  lavage  is  best  carried  out  with 
sodium  bicarbonate,  and  thereafter  with  argentic  nitrate  or  bismuth 
subnitrate.  The  pyrosis,  distention,  and  constipation  are  much 
relieved  thereby.  In  cases  of  much  accumulation  of  mucus,  warm 
alkaline  and  saline  solutions  are  preferable ;  for  in  the  gastritis  mucosa 
the  HCl  secretion  is  lost,  and  common  salt  is  a  stimulant  to  that 
secretion — if  there  be  any  secreting  glandular  cells  left.  I  have  found 
that  sulphocarbolate  of  zinc,  in  the  strength  of  one  grain  to  one  ounce 
of  water,  will  check  excessive  secretion  of  mucus  in  chronic  gastritis. 
It  is  used  in  the  intragastric  spray  after  previous  lavage.  Toxic 
products  of  complex  nature  may  accumulate  in  the  organ,  in  conse- 
quence of  carcinoma,  uremia,  and  diabetes  mellitus;  here  lavage  is 
also  indicated.  During  the  lavage  one  should  always  have  a  second 
glass  vessel,  holding  one  liter,  into  which  the  outflow  discharges,  so 
that  it  may  be  ascertained  each  time  how  much  is  regained.  It  is 
very  dangerous  to  wash  out  the  stomach  with  medicated  and  anti- 
septic solutions  without  ascertaining  whether  all  the  solution  flows 
out  again.  Even  with  simple  water,  overloading  of  the  stomach 
can  not  be  avoided  except  by  measuring  the  outflow.  In  a  paper 
published  in  the  "Practitioner"  (1892,  No.  4)  W.  Soltau  Fenwick 
reports  three  cases  of  poisoning  from  leaving  antiseptic  solutions  in 
the  stomach.  In  one  case  ("Schmidt's  Jahrbiicher,"  1883,  Bd. 
cxcviii,  p.  28)  death  was  caused  in  six  days  by  leaving  a  two  to 
three  per  cent,  solution  of  boric  acid  in  the  stomach.     Fenwick  also 


THE    GASTRIC    DOUCHE. 


^OI 


makes  a  strong  plea  against  the  indiscriminate  use  of  antiseptics 
within  the  stomach,  for  the  alimentary  canal  is  endowed  with  the 
power  of  absorbing  not  only  the  poisonous  products  of  the  bacteria, 
but  also  most  of  the  substances  which  are  introduced  to  destroy 
them  (W.  S.  Fenwick,  "Disorders  of  Digestion  in  Infancy,"  etc., 
p.  141). 

Tetany  has  been  observed  after  lavage  by  Bouveret  and  Devic, 
who  collected  twenty-one  cases  ("Revue  de 
Med.,"  Februar}-,  1892).  In  all,  thirty-four  such 
cases  of  tetany  of  gastric  origin  have  been  re- 
ported, though  not  all  due  to  lavage.  Ewald 
reported  two  cases  that  are  of  interest — one  a 
male,  aged  forty-five,  who  died  from  a  sud- 
den, copious,  esophageal  hemorrhage  two  days 
after  he  had  sought  relief  b)^  introduction 
of  the  esophageal  sound.  There  were  symp- 
toms of  mediastinal  tumor  or  aneurysm.  The 
second  patient  died  suddenly  while  he  was  intro- 
ducing the  tube  himself;  the  autopsy  showed 
a  dissecting  aneurysm  at  the  beginning  of  the 
ascending  aorta,  still  within  the  pericardium. 
Frerichs  and  Penzoldt  have  reported  similar 
cases.  Every  new  patient  should,  therefore,  be 
examined  for  abnormal  conditions  within  the 
thorax  before  lavage. 

The  Gastric  Douche. — By  douching  the  stom- 
ach, is  meant  an  internal  irrigation  with  water 
under  high  pressure.  It  was  first  practised  at 
Kussmaul's  clinic,  and  described  later  by  Mal- 
branc  ("On  the  Treatment  of  Gastralgias  by  the  Internal  Gastric 
Douche,"  etc.,  "Berlin,  klin.  Wochenschr.,"  1878,  No.  4).  It  does 
not  differ  essentially  from  ordinary  lavage  except  in  the  fact  that 
the  funnel  or  vessel  into  which  the  water  is  poured  is  held  at  least 
one  meter  above  the  cardia.  Rosenheim  improved  and  revived 
the  method,  after  it  had  been  disregarded  for  twelve  years,  by  de- 
vising a  special  douching  tube  with  numerous  very  small,  lower 
openings  instead  of  one  or  two  large  ones.  Water  that  is  allowed 
to  run  into  the  stomach  through  such  a  tube  under  high  pressure 
strikes  the  walls  with  many  currents  of  considerable  impetus.  The 
central  or  terminal  opening  in  Rosenheim's  douche  tube  is  larger 


Fig.  25.— Recurrent 
Gastric  Needle 
Spray  or  Douche. 


302  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

than  the  lateral  ones,  and  permits  of  an  easy  outflow.  Dr.  F.  B. 
Turck,  of  Chicago,  has  devised  a  stomach  needle  douche  with  a 
separate  outflow  tube;  it  also  produces  an  intragastric  shower  (Fig. 
25),  and  is  a  useful  instrument. 

Rosenheim  recommends  the  douche  for  nervous  dyspepsia  and 
chronic  gastritis,  with  or  without  impaired  motility.  If  the  douch- 
ing was  done  with  solution  of  sodium  chlorid  an  increase  in  the  HCl 
production  could  be  ascertained;  whereas  nitrate  of  silver  caused  a 
reduction  of  the  secretion  ("Berlin.  Klinik,"  1894,  Heft  71).  Riegel 
speaks  well  of  argentic  nitrate  applied  in  this  manner  for  all  irritative 
states  of  secretion  {loc.  cit.,  p.  300). 

Fleiner  has  called  attention  to  the  fact  that  he  and  Kussmaul 
could  incite  a  feeling  of  hunger  by  douches.  These  clinicians  in- 
creased the  effect  by  irrigating  the  gastric  mucosa  with  solutions  of 
bitter  tonics :  hops  and  quassia  were  experimented  with. 


e.TIEMANNS-CO. 
'  Fig.  26. — Einhorn's  Intragastric  Spray. 

In  severe  cases  of  anorexia  we  have  tried  this  method  with  infu- 
sions of  gentian  and  cinchona,  and  were  pleased  with  the  effects. 
Einhorn  has  invented  an  intragastric  spray  (Fig.  26),  which  is  recom- 
mended for  disinfection  of  the  mucosa,  to  produce  an  astringent  or 
an  anesthetic  effect.  It  is  surprising  what  a  trifling  amount  of 
cocain  is  necessary  to  relieve  a  gastralgia  when  used  in  this  manner. 
For  gastric  erosions  the  nitrate  of  silver  spray  (i  :  1000)  is  frequently 
curative.  For  excessive  secretion  of  mucus  zinc  sulphocarbolate, 
one  grain  to  one  ounce  of  water,  can  be  recommended.  The  gastric 
douche  and  spray  should  be  applied  only  in  an  empty  stomach. 
Motor  impairment  of  nervous  origin  is  occasionally  much  improved 
by  alternately  douching  with  warm  (100°  C.)  and  cold  water. 

Electricity  in  the  Treatment  of  Gastric  Diseases. — The  effect 
of  electricity  on  the  various  functions  of  the  stomach  has  been  already 


ELECTRICITY    IN   THE   TREATMENT   OE    GASTRIC    DISEASES.       303 

referred  to  under  the  consideration  of  the  motor  function  and  will 
be  further  described  under  the  various  diseases  in  which  it  is  recom- 
mended. The  results  of  physiological  experiment  and  of  clinical 
experience  are  largely  contradictory.  Physiological  experiments, 
when  conducted  by  medical  men,  are  frequently  inexact  and  mis- 
leading. It  requires  special  physiological  laboratory  training  of  years 
to  control  the  technics  of  vivisection  and  general  experimentation. 
In  the  experiments  of  medical  men  on  the  physiological  effects  of 
electricity  it  is  not  difhcult  to  find  numerous  defects  in  the  physics 
and  physiology  of  the  methods  used,  the  conduct  and  the  execution 
of  the  experiment,  etc.,  which  render  their  results  invalid  from  the 
outset;  so  that  it  is  useless  to  go  into  the  literature  of  the  history 
of  gastric  electrotherapy  exhaustively.  Many  experimenters  fail  to 
give  the  details  and  conditions,  the  kind  of  cell  used,  the  number  of 
milliamperes,  the  number  of  faradic  stimulations  to  the  minute,  the 
kind  of  electrode,  the  distance  of  primary  from  secondary  coil.  Con- 
trol experiments  are  wanting  to  ascertain  whether,  in  the  same 
animal,  peristalsis  could  not  be  observed  per  se  without  stimulation 
by  electricity,  or  whether  the  stimulation  may  not  have  been  purely 
mechanical,  not  electrical. 

From  a  clinical  standpoint  it  is  not  necessary  to  demonstrate 
that  electricity  can  produce  changes  in  the  chemistry,  resorption, 
and  motility  of  the  stomach  in  order  to  justify  its  employment; 
for  there  may  be,  and  probably  are,  influences  exerted  by  electricity 
Upon, the  nutrition  of  living  cells  which  as  yet  escape  our  methods  of 
analysis.  The  effect  of  electrical  stimulation  of  the  cells  of  spinal 
ganglia,  as  seen  and  determined  by  micrometric  measurement,  and 
consisting  in  a  loss  of  bulk  mainly  in  the  nuclei,  was  first  described  by 
C.  F.  Hodge,  in  the  "American  Jour,  of  Psychology"  for  May,  1888, 
and  May,  1889.  Judging  from  these  experiments,  which  were  con- 
ducted with  exemplary  accuracy  and  regard  for  physiological  detail, 
it  is  reasonable  to  presume  that,  in  some  way  or  other,  the  metabol- 
ism of  muscle-,  gland-,  and  nerve-cells  of  the  stomach  may  be  in- 
fluenced by  electricity.  The  demonstration  of  this  is  a  future  pros- 
pect ;  at  present  the  main  reason  why  we  employ  this  agent  is  simply 
because  we  know  that  in  certain  diseases  it  is  of  much  benefit.  Physi- 
ology jnay  come  to  our  aid  later  on,  and  tell  us  why  it  is  that  these 
results  are  produced.  From  the  work  done  by  medical  physiologists 
so  far,  no  clear  deductions  are  possible. 

The  electrical  stimulation  of  the  vagus  in  a  subject,   forty-five 


304  LAVAGE    AND   THE    GASTRIC    DOUCHE. 

minutes  after  execution,  which  was  carried  out  by  Beynard  and 
Loye  ("Progres  Medicale,"  1885,  No.  29),  and  produced  a  secretion 
of  gastric  juice,  has  strengthened  the  behef  that  the  vagus  contains 
gastric  secretory  fibers.  Ziemssen  ("KHnische  Vortrage,"  No.  12, 
1887),  Rossi  ("IvO  Sperim.,"  1881),  and  Hoffmann,  who  experi- 
mented at  Riegel's  cHnic  ("Berhn.  kHn.  Wochenschr.,"  1889,  No. 
12),  all  arrived  at  the  conclusion  that  electricity  promoted  the 
secretion  of  gastric  juice. 

The  results  of  investigations  concerning  the  influence  of  the  two 
kinds  of  currents — the  constant  and  the  interrupted — differ  widely. 
Einhorn  was  of  the  opinion  that  the  faradic  current  promoted  secre- 
tion and  the  galvanic  impeded  it  ("Deutsche  med.  Wochenschr.," 
1893;  also  "Zeitschr.  f.  klin.  Med.,"  Bd.  xxiii).  The  experiments 
of  Hoffmann  (loc.  cit.)  suggested  that  the  galvanic  current  favored 
an  increased  secretion,  while  Brocci's  results  with  intragastric  fara- 
dization would  have  us  believe  that  in  animals  the  interrupted  cur- 
rent can  augment  both  peristalsis  and  secretion  ("Lo  Sperimentale, " 
Giugno,   1 881). 

Concerning  the  effect  of  electricity  on  the  motor  function  we 
might  quote  a  few  experimenters.  Schillbach  ("Virchow's  Arch.," 
Bd.  Cix,  p.  284)  produced  strong  contractions  at  the  site  of  the 
anode  by  applying  the  galvanic  current  to  the  intestines  of  a  rabbit. 
Von  Ziemssen  (Joe.  cit.),  Bocci  {loc.  cit.),  L/udwig,  and  Weber  have 
stated  that  the  faradic  as  well  as  the  galvanic  current  applied  di- 
rectly to  the  stomach  cause  contraction  of  the  same  in  animals. 
Fubini  ("Centralbl.  f.  med.  Wiss.,"  1882,  No.  33)  concluded  that 
electricity  accelerates  intestinal  peristalsis;  he  experimented  on 
Vella's  double  intestinal  fistula.  Two  Americans,  Rockwell  and 
Beard  ("Phila.  Medical  and  Surgical  Reporter,"  1868,  No.  20),  were 
among  the  first  to  employ  electricity  in  the  treatment  of  nervous 
dyspepsia. 

In  Pepper's  case  of  spontaneous,  visible,  gastric  peristalsis  (' '  Phila. 
Med.  Times,"  1871,  p.  274)  no  peristaltic  movements  could  be  pro- 
duced by  applying  electricity  percutaneously.  Kussmaul,  in  1877, 
stated  that  "the  therapeutic  results  obtained  by  Flirstner  in  gas- 
trectasias  did  not  prove  that  an  actual  peristalsis  was  produced  by 
the  current,  but  they  were  probably  due  to  contraction  of  the  abdom- 
inal muscles"  ("Archiv  f.  Psychiatric  u.  Nervenkrankh.,"  1878,  p. 
205).  Canstatt  first  suggested  treating  dilatations  by  placing  one 
electrode  in  the  esophagus,  the  other  on  the  stomach ;  and  Duchenne 


EFFECT  OF  ELECTRICITY  ON  GASTRIC  PERISTALSIS. 


305 


first  actually  applied  this  method  (both  the  latter  quoted  from 
Kussmaul,  loc.  cit.).  In  1877  Kussmaul  {loc.  cit.)  began  introducing 
intragastric  electrodes,  made  by  inserting  a  copper  wire  in  a  stomach- 
tube,  the  wire  terminating  in  a  little  exposed  knob  which  came  in 
direct  contact  with  the  inner  gastric  surface. 

Bardet  improved  this  method  by  a  similar  electrode,  which,  how- 
ever, did  not  come  in  contact  with  the  mucosa  in  one  spot  only,  but 
by  a  quantity  of  water  previously  taken  it  was  distributed  over  the 
entire  surface  (Bardet,  "Bull.  Gen.  de  Therap.,"  1884).  Ziemssen 
then  employed  a  similar  device,  but  Einhorn  completed  the  evolu- 
tion of  the  intragastric  electrode  by  originating  a  soft,  very  plastic, 


C.TIEMANM&CQ. 


Fig.  27.— Rectal  Electrode. 


OEO.TIEMANN  CO. 
Fig.  28.— Einhorn's  Intragastric  Electrode. 


deglutable  instrument,  the  end  of  which  is  inclosed  in  an  ovoid, 
perforated,  hard-rubber  cap.  Ewald  prefers  Einhorn's  electrode  a 
little  more  rigid,  so  that  it  can  be  pushed  into  the  stomach  and  need 
not  necessarily  be  swallowed.  The  thickness  of  the  rubber  tube 
in  Ewald's  modification  is  i^  mm.  Rosenheim  {loc.  cit.),  Wegele 
("Therap.  Monatshefte,"  April,  1895),  Charles  G.  Stockton  ("A  New 
Gastric  Electrode,"  "Medical  Record,"  Nov.  9,  1889),  and  F.  B. 
Turck  have  later  devised  electrodes  for  this  purpose  which  represent 
no  advance  over  those  mentioned.  The  thin-wired  electrode  of 
Einhorn  (Fig.  28)  possesses  the  advantage  that  it  can  be  swallowed 
by  those  not  used  to  the  stomach-tube,  to  which  they  must  become 
accustomed  in  case  Wegele's,  Stockton's,  or  Rosenheim's  electrode 


3o6  lavage;  and  the;  gastric  douche. 

is  employed.  The  inclosing  tube  of  Einhorn's  instrument  is  really 
too  thin,  however,  for  in  our  experience  it  rapidly  wears  through 
near  the  connection  with  the  hard-rubber  end-cap,  and  we  consider 
Bwald's  modification  safer,  more  durable,  and  of  easier  introduction. 
These  results  correspond  in  the  main  with  those  previously  pub- 
lished by  Meltzer  ("New  York  Med.  Jour.,"  June  15,  1895),  whose 
experiments  were  conducted  with  great  care,  and  from  a  physio- 
logical aspect  are  beyond  reproach.  We  should  have  preferred 
knowing  how  many  vibrations  to  the  second  Meltzer  used,  since  we 
have  assured  ourselves  that  when  too  many  stimulations  to  the 
second  are  thrown  into  a  muscle,  particularly  an  involuntary  muscle, 
it  will  not  contract  at  all;  whereas  the  same  muscle  will  contract 
if  a  smaller  number  of  stimulations  be  used  (judged  by  the  Kronecker 
interrupter  and  a  Jacquet  chronograph).  These  facts  were  first 
stated  in  an  article  in  the  "New  York  Med.  Jour."  (Hemmeter, 
"Recording  Motor  Functions  of  the  Stomach,"  "New  York  Med. 
Jour.,"  June  22,  1895,  p.  772).  We  used  an  intragastric  deglutable 
rubber  bag  (see  illustrations,  plate  iv),  which  had  small  brass  knobs 
extended  at  any  desirable  location,  and  when  the  bag  was  distended 
by  blowing  it  up  within  the  stomach  the  end  electrodes  pressed 
directly  against  the  muocsa — usually  one  at  the  pylorus  and  one  in 
the  fundus ;  the  bag  was  in  connection  with  a  tambour  or  manometer 
recording  on  the  Ludwig  kymographion.  We  have  already  briefly 
stated  that  we  were  unable  to  produce  any  contraction  of  the  human 
or  animal  stomach  with  the  strongest  currents  to  be  obtained  from 
one  Grove  cell  prepared  anew  for  each  experiment,  and  the  distance 
of  the  primary  from  the  secondary  coil  equal  to  zero  when  both 
electrodes  were  within  the  stomach  touching  the  mucosa.  We  have 
elsewhere  given  our  studies  on  the  resistance  which  fresh  human 
gastric  mucosa  offers  to  the  constant  current,  and  in  the  main  can 
confirm  Meltzer  that  perdutaneous  and  direct  faradization  of  the 
stomach  and  intestines  can  produce  no  contraction  of  these  parts. 
Not  every  current  which,  according  to  magnetic  needles  or  the 
milliamperemeter,  actually  penetrates  the  gastric  wall  causes  con- 
traction. For  instance,  with  one  electrode  within  the  stomach  of 
man  or  dog,  and  another  on  the  gastrocnemius,  the  skeletal  muscle 
may  contract  vigorously  and  the  stomach  remain  passive.  Again, 
in  human  subjects  the  factors  of  natural  peristalsis  occurring  under 
the  nervous  tension  due  to  the  experiment,  and  of  suggestion,  can 
not  be  satisfactorily  eliminated. 


EFFECT   OF   ELECTRICITY   ON   GASTRIC   PERISTALSIS.  307 

In  a  recent  publication  Hinhorn  has  attempted  to  disprove  the 
experiments  of  Meltzer,  but,  as  far  as  can  be  judged  from  the  report 
of  the  former  (in  the  "Archiv  f.  Verdauungskrankheiten,"  Bd.  11, 
p.  454),  the  experiments  were  not  conducted  along  the  same  lines 
nor  with  the  same  regard  for  physiological  detail  as  those  of  Meltzer. 
Einhorn  gives  brief  synopses  of  eighteen  experiments,  twelve  of 
which  were  made  with  frogs,  with  which  Meltzer  did  not  work,  and 
from  the  results  of  which  conclusions  regarding  the  mammalian 
stomach  can  not  be  safely  drawn.  Three  animals  were  rabbits;  in 
these  the  stomach  is  always  full  of  ingesta,  unless  starved.  Two 
were  rats ;  one  only  was  a  dog ;  the  latter  was  the  animal  with  which 
Meltzer  mainly  worked.  Nor  is  it  evident  that  Einhorn's  results, 
as  stated  by  him,  contradict  those  of  Meltzer  in  salient  points.  Tak- 
ing, for  instance,  the  last  experiment  with  the  dog,  Einhorn  made 
three  kinds  of  stimulations  with  the  double  electrode:  (i)  on  the 
serous  (peritoneal)  surface,  near  the  fundus — contraction;  (2)  on  the 
peritoneal  surface  over  the  pylorus — strong  contraction;  (3)  opening 
of  the  stomach, — one  electrode  against  the  mucosa,  the  other  on  the 
peritoneal  layer  outside;  a  weak  current  causes  slight  peristaltic 
contractions. 

Meltzer  does  not,  in  his  original  paper,  deny  any  of  these  possi- 
bilities ;  even  the  contraction  of  the  third  experiment  was  witnessed 
by  him  when  the  inner  electrode  on  the  mucosa  was  placed  near  the 
outer  one  on  the  serosa.  But  with  bipolar  internal  stimulation — 
i.  e.,  with  both  electrodes  on  the  mucosa — even  Einhorn  does  not 
claim  to  have  obtained  any  peristalsis  of  considerable  tonicity.  We 
incline  to  the  opinion  that  satisfactory  evidence  has  not  yet  been 
furnished  that  internal  electric  stimulation  can  influence  secretion  or 
motility  either  way.  This  conclusion  has  been  reached  after  years 
of  experimenting  on  both  functions  in  the  Biological  Laboratory  of 
the  Johns  Hopkins  University. 

In  a  recent  reply  to  Einhorn's  criticism,  Meltzer  accepts  the  ex- 
planation of  the  former,  concerning  the  difficulty  of  penetration  of 
the  electric  current  to  the  muscular  layer  (Boas'  "Archiv  f.  Ver- 
dauungskrankh.,"  Bd.  iii,  Heft  2,  S.  133).  This  may  be  caused, 
according  to  Einhorn,  by  the  mucosa  being  a  bad  conductor  as  well 
as  by  its  being  a  very  good  conductor — leading  the  current  away 
from  the  point  of  contact.  We  have  shown  conclusively  that  the 
fresh  normal  human  mucosa  is  a  poor  electric  conductor.  Einhorn, 
however,  assumes  that  the  mucosa  conducts  so  well  that  the  current 


3o8  lavage;  and  the  gastric  douche. 

does  not  reach  the  muscularis,  because  it  moves  in  the  direction  of 
least  resistance — in  the  glandular  layer  itself.  Tests  made  with  the 
mucosa  peeled  off  from  the  other  layers  of  the  stomach  of  a  dog 
under  narcosis,  with  the  milliamperemeter  in  the  circuit,  show  that 
the  fresh  mucosa  is  practically  a  non-conductor. 

Indications  for  the  Employment  of  Electricity  and  Manner  of  Appli- 
cation.— Direct  gastric  faradization  is  recommended  for  dilatations 
due  to  relaxation  of  the  musculature,  but  not  to  stenosis,  whether 
these  cases  are  associated  with  reduced  secretion  or  not.  Relaxa- 
tions of  the  cardia  or  pylorus  are  benefited  b};-  the  faradic  current. 
Sensory  disorders  (gastralgia)  are  successfully  treated  with  direct 
galvanization.  Rosenheim  {loc.  cit.)  believes  that  the  galvanic  cur- 
rent is  more  effective  in  debility  of  the  peristalsis.  In  all  symptoms 
of  sensory  irritation  he  prefers  the  constant  current  also,  but  in 
secretory  disturbances  he  has  ceased  to  use  electricity ;  and  we  agree 
with  him  that,  in  the  latter  class,  more  can  be  accomplished  by 
medicated  douches  and  adapted  acid  or  alkaline  and  bitter  tonic 
medicines  than  with  electricity.  Brock  confirms  the  good  effect  of 
galvanism  on  the  course  of  gastric  neuroses  ("Therap.  Monatshefte," 
June,  1895),  though  he  is  not  so  enthusiastic  as  Einhorn. 

According  to  Goldschmidt,  there  are  no  distinct  differences  be- 
tween the  effects  of  direct  galvanization  and  direct  faradization; 
but  nevertheless  he  recommends  the  former  for  the  painful,  the  latter 
for  the  functional  disturbances  of  the  stomach.  In  contrast  with 
those  mentioned,  von  Ziemssen  prefers  the  percutaneous  to  the  direct 
intragastric  application;  his  reasons  are  not  very  convincing,  in  the 
light  of  Meltzer's  and  Goldschmidt 's  experiments.  The  electric 
brushing  of  the  skin  of  the  abdomen,  breast,  and  back,  urged  by  von 
Ziemssen,  seems  to  be  a  great  stimulus  for  nervous  energy  in  neu- 
ropathic cases. 

In  this  country,  Allen  A.  Jones  ("Med.  Rec,"  June  13,  1891), 
Charles  G.  Stockton  ("Med.  Rec,"  1889,  p.  530),  and  D.  D.  Stewart 
("Therap.  Gazette,"  1893,  p.  744)  have  published  clinical  observa- 
tions on  the  intragastric  employment  of  electricity,  and  there  is  a 
fairly  uniform  agreement  that  the  class  of  gastric  neuroses,  par- 
ticularly the  sensory  neuroses,  nervous  vomiting,  and  anorexia,  are 
special  indications  for  electricity  in  the  form  of  the  constant  current, 
and  that  the  direct  intragastric  method  is  to  be  preferred  to  the 
percutaneous. 

In  simple  atony  and  atonic  dilatations  (but  not  in  those  depend- 


HYDROPATHIC    AND    ORTHOPEDIC    METHODS.  309 

ent  Upon  pyloric  obstruction)  the  preference  is  to  be  given  to  the 
direct  faradic  current.  The  manner  of  application  is  simple;  the 
anode  is,  as  a  rule,  swallowed,  and  forms  the  intragastric  pole.  The 
cathode  must  have  the  shape  of  a  conveniently  broad  and  long,  felt- 
covered  plate  (Fig.  29),  which,  after  it  is  dipped  in  warm  water,  is 
placed  for  ten  minutes  on  the  epigastrium;  thereafter  passed  slowly 
up  and  down  over  the  spinal  column  from  the  cervical  to  the  sacral 
region.  The  meter  should  always  be  in  the  circuit,  in  case  the 
galvanic  current  is  used,  and  the  strength  of  the  current  be  about 
twenty-five  milliamperes.     The 


electric  bath,  or  electricity 
applied  when  the  body  is 
immersed  in  a  saline  bath,  has 
its  advantages  in  gastric  neu- 
roses. 

For  more  complete  literature      | 
of  the  subject  the  reader  is  re-      k 

f erred  to  the  writings  of  Kuss-      1^^  ceq.tjE'jMANn  ^co 

maul  (loc.  cit.),  Einhorn  {loc.  cit., 

and     Einhorn,     "  Berhn.     klin.  ^''^-  29.-abdom.nal  electrode. 

Wochenschr.,"     1891,    No.     23; 

also  "Zeitschr.  f.  klin.  Med.,"  1893,  xxiii,  p.  369),  and  Goldschmidt 
("Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xv,  p.  295).  The  latter  in- 
vestigator worked  under  Moritz,  whose  capital  experiments  on  the 
motility  we  have  already  abstracted.  Goldschmidt  concludes  that  the 
"direct  faradization  and  galvanization  of  the  stomach  (distance  of 
primary  from  secondary  coil  =  zero,  duration  fifteen  to  twenty- 
five  minutes)  has  only  an  unimportant  and  inconstant  influence  on 
the  peristalsis,  and  on  secretion  it  has  no  influence  whatever." 

Hydrotherapeutic  and  Orthopedic  Methods. — Hydriatic  pro- 
cedures are  much  lauded  by  German  and  French  gastro-enterologists. 
Most  of  these  methods  can  influence  the  stomach  only  indirectly  and 
secondarily,  and  therefore  are  of  greater  utility  in  functional  dis- 
turbances than  in  the  organic  gastric  diseases.  These  methods  may 
be  divided  into  (i)  general  or  systemic,  (2)  special  or  local  hydro- 
therapic  treatments.  The  method  to  employ  depends  more  upon 
the  state  of  general  health  and  the  condition  of  the  nervous  system 
than  upon  any  local  condition.  Wherever  hydriatic  treatment  be- 
comes necessary,  it  is  imperative  to  send  the  patient  to  some  well- 
managed  institution,  as  most  of  the  procedures  can  not  be  executed 


3IO  LAVAGE   AND   THE    GASTRIC    DOUCHE. 

at  home.  Among  the  methods  most  employed  are  the  various  local 
and  general  douches — viz.,  fan  douche;  cold,  hot,  graduated,  Scotch, 
and  French  douches.  Among  these  we  have  tried  the  Scotch  douche 
most  frequently  in  gastric  myasthenia.  It  consists  of  a  stream  of 
moderate  intensity  directed  against  the  epigastrium  for  three  or  four 
minutes.  But  during  this  time  the  temperature  of  the  water  is 
changed  every  ten  or  twenty  seconds  from  28°  to  8°  R.,  or  vice 
versa;  it  is  much  lauded  by  von  Ziemssen  and  Rosenthal  ("]\Iagen- 
neurosen,"  etc.,  Wien,  1886).  There  are,  besides,  many  kinds  of 
fine  sprays,  and  the  sponge,  sea-salt,  pour,  dash,  shower,  shallow, 
vapor,  and  sitz-baths;  also  a  variety  of  packs,  fomentations,  and 
compresses  (see  Baruch,  "Hydrotherapy").  A  local  application 
which  is  very  soothing  in  gastralgic  affections  is  the  so-called  Pries- 
snitz  pack,  which  consists  simply  of  a  towel  folded  together  to  the 
size  of  six  by  ten  inches,  and  dipped  into  hot  or  cold  water,  wrung 
out  so  that  there  is  no  dripping  from  it,  and  then  applied  to  the 
epigastrium;  a  layer  of  oiled  silk  or  gutta-percha  paper  is  laid  over 
it  and  the  whole  is  snugly  secured  and  held  in  place  b}^  a  broad  flannel 
bandage  passed  around  the  body.  As  a  matter  of  fact,  most  patients 
feel  relieved  and  free  from  pain,  but  how  the  quieting  effect  is  pro- 
duced is  a  matter  of  conjecture. 

In  the  treatment  of  gastric  ulcer  hot  cataplasms  are  very  service- 
able. We  are  in  the  habit  of  using  spongiopiline  dipped  into  hot 
water  and  applied  to  the  epigastrium  after  the  excess  of  water  is 
pressed  out. 

The  orthopedic  appliances  used  in  the  treatment  of  gastric  diseases 
are  often  only  imperfect  substitutes  for  the  more  lasting  effects  of 
proper  operations.  They  consist  of  contrivances  to  support  the 
stomach  in  gastroptosis,  or  to  keep  up  a  floating  kidney  and  prevent 
its  interfering  with  the  gastric  or  intestinal  peristalsis.  Where  the 
abdominal  muscles  have  become  so  relaxed  that  they  seem  to  drag 
the  viscera  downward  instead  of  supporting  them,  a  condition  found 
in  obesity  (Hangebauch  =  pendulous  abdomen),  the  Landau  abdom- 
inal corset,  for  both  sexes,  has  proven  of  undoubted  usefulness  in 
many  cases  in  the  author's  practice.  Abdominal  gymnastics  are  the 
most  effective  prophylaxis  against  these  conditions. 

Gastric  Massage. — Von  Ziemssen  ("Ueber  d.  physik.  Behandl. 
chronischer  Magen-  und  Darmleiden,"  Leipzig,  1S88,  p.  29)  and 
Rosenheim  (loc.  cit.,  p.  146)  consider  massage  a  ver}^  subordinate 
means  of  treatment  for  stomach  diseases.     Ewald   {loc.  cit.),   Boas 


INDICATIONS   FOR   GASTRIC   MASSAGE). 


311 


{loc.  cit.),  and  Riegel  (loc.  cit.),  however,  believe  that  there  is  some- 
thing of  value  in  the  treatment.  The  best  study  of  gastric  massage 
was  published  by  Zabludowsky  ("Berlin,  klin.  Wochenschr.,"  1886, 
No.  26)  and  Cseri  ("Wien.  med.  Wochenschr.,"  1889).  The  technic 
of  massage  differs  according  to  the  object  to  be  accomplished.  If 
it  is  intended  as  a  passive  exercise  to  strengthen  the  musculature, 
it  is  best  done  on  an  empty  stomach,  in  bed  before  breakfast.     But 


Fig.  30.— Massage  of  the  Stomach  in  Dilatation  or  Gastroptosis.- 
{Penzoldt  and  Stintzing ,  "■  Handbuck  d.  Therapie,"  etc.) 


if  the  massage  is  expected  to  assist  in  the  expulsion  of  chyme,  it 
should  be  undertaken  three  or  four  hours  after  the  principal  meals. 
Massage  can  not  be  properly  performed  except  on  the  uncovered 
skin.  Indications  for  massage  are  given  in  the  disturbances  of  the 
motor  functions,  viz. :  (i)  Those  depending  on  myasthenia  or  atony; 
(2)  depending  on  a  stenosis  of  moderate  degree;  (3)  cases  of  re- 
duced secretion  and  chronic  gastritis;  (4)  gastroptosis  or  prolapse 
of  the  stomach;  and  (5)  certain  cases  of  nervous  inhibition  of  peri- 


312  GASTRIC   massage;. 

stalsis.  In  cancer,  ulcer,  hematemesis,  all  acute  inflammations  in 
or  around  the  organ,  in  excessive  dilatation,  distention,  or  contrac- 
tion, and  in  all  cases  of  intragastric  putrefaction,  massage  is  contra- 
indicated. 

Massage  of  the  stomach  and  colon  is  generally  practised  with  a 
view  to  support  and  strengthen  the  expulsive  power  of  these  organs ; 
secondarily,  its  use  may  promote  the  nutrition  of  the  mucosa  and 
favor  the  resorption  of  infiltrations. 

The  technic  varies  with  the  indication.     For  improving  the  mus- 


FiG.  31.— Massage  for  Improving  Gastric  Tonicity.— (/Vw^o/rf/  and  Stintzing, 
'^  Handbuch  d.    Therapie,"  etc.) 


cular  tone  of  the  empty  stomach  the  masseur  places  himself  to  the 
right  of  the  patient,  who  must  lie  on  his  back  with  knees  slightly 
flexed.  First  movement  (a) :  Insert  the  left  hand  slowly  and  gradu- 
ally deeply  under  the  left  arch  of  the  false  ribs,  under  and  past  the 
edge.  To  increase  the  pressure,  gently  press  the  right  hand  firmly 
on  the  left.  Second  movement  (6) :  Now  describe  small  circles  with 
the  hands  thus  arranged,  progressing  slowly  from  the  pylorus  to  the 
fundus.  Third  movement  (c) :  Perform  strong  vibratory  move- 
ments toward  the  depth  with  the  finger-tips,  while  a  and  h  are  being 
executed.     Fourth    movement    {d) :  Knead    the    stomach    between 


TECHNICS   Olf   GASTRIC   MASSAGE. 


313 


thumb  and  four  fingers,  and  in  conclusion  execute  stroking  passes, 
with  extended  four  fingers,  from  left  to  right. 

Massage  of  the  full  stomach  is  undertaken  with  a  view  to  mix  its 
contents  thoroughly  or  to  aid  in  forcing  them  into  the  duodenum, 
/^abludowski  {loc.  cit.)  advises  the  pressing  of  the  stomach  against 
the  spinal  column,  dividing  it  into  halves;  by  compressing  the  half 
nearest  the  pylorus,  he  widens  the  latter  by  wedging  the  chyme 
through  it  into  the  duodenum.  This  is  justifiable  only  where  it  is 
sure  that  the  chyme  is  comparatively  fresh,  and  not  in  a  state  of 


Fig.  32. — Massage  of  the  Stomach  and  of  the  Colon. — {Penzoldl  and  Stintzing, 
"  Handbuch  d.   Thei  apie ,^^  etc.) 


putrefaction.  The  author  has  repeatedly  experimented  with  Zablu- 
dowski's  method,  and  frequently  failed.  It  is  doubtful  whether  the 
contents  of  very  dilated  stomachs  can  be  expressed  into  the  duo- 
denum by  massage. 

Combination  of  Massage  and  Medicated  Irrigations  of  Stom- 
ach and  Colon. — When  solutions  of  chemicals  are  poured  into  the 
stomach  or  swallowed,  they  exert  a  more  prompt  and  lasting  effect 
if  the  organ  is  subjected  to  gentle  massage  during  the  time  these 
solutions  are  in  it.     In  case  there  has  been  retention  of  ingesta  and 


314  GASTRIC   massage;. 

processes  of  putrefaction,  the  stomach  must  first  be  thoroughly 
cleansed  by  lavage.  If  the  solutions  contained  active  chemicals  they 
must  be  removed  after  the  massage  by  careful  irrigation  with  plain 
water. 

This  treatment  is  indicated  in  hyperacidity  with  alkaline  solutions^ 
in  sub-  or  anacidity  with  diluted  HCl  and  all  conditions  of  chronic 
hyperemia,  excepting  the  active  processes  given  above  as  contra- 
indications. In  states  of  relaxation  of  muscular  tonus  and  in  hyper- 
esthesia and  gastralgia  we  have  observed  most  gratifying  improve- 
ment where  other  methods  had  proved  futile. 

The  technics  of  the  method  are  simple :  in  some  cases  the  patient 
may  be  permitted  to  drink  the  medicated  solutions,  but  it  will  gener- 
ally be  preferable  to  pour  them  in  through  the  tube,  especially  when 
lavage  is  indicated  before  the  procedure.  The  taste  of  some  of  the 
drugs  that  are  necessary,  prevents  drinking  the  solutions,  or  it  may 
be  requisite  that  the  mouth  or  esophagus  be  protected  from  the 
agents.  As  soon  as  the  solution  is  in  the  stomach,  the  patient  oc- 
cupying the  dorsal  recumbent  position,  with  the  knees  flexed,  the 
masseur  begins  with  gentle  but  deeply  penetrating  compression  of 
the  epigastrium  and  hypogastrium  with  palmar  surface  of  the  fingers. 
Thereupon  stroking  of  the  stomach  region  from  above  downward;, 
from  left  to  right,  and  reversely ;  next  follow  circular  friction  move- 
ments of  the  stomach  especially,  but  also  over  the  entire  abdomen. 
During  the  massage  the  dorsal  position  should  be  exchanged  with 
the  right  and  left  lateral  position.  The  medicines  inside  the  organ 
will  in  this  manner  be  extensively  and  thoroughl}^  brought  in  con- 
tact with  the  gastric  walls,  and  it  is  conceivable  that,  through  the 
increased  circulation  effected  thereby,  absorption  is  favored  in  a 
manner  not  otherwise  obtainable.  The  duration  of  this  method 
should  not  exceed  ten  minutes  with  indifferent  substances,  and 
only  five  minutes  if  chemicals  with  a  decided  effect  are  used.  The 
agents  that  have  been  employed  are  the  following :  In  anacidity  and 
achylia,  HCl  2:1000;  also  normal  salt  solutions  and  one  per  cent, 
of  ichth3^ol.  In  anorexia,  solutions  of  the  tinctures  of  Colombo, 
calisaya,  quassia,  gentian,  and  hops.  In  hyperacidity,  the  natural 
alkaline  mineral  waters,  such  as  Saratoga  Vichy,  or  ^  per  cent,  solu- 
tion of  Carlsbad  salts.  Jaworski's  antacid  solution  is  useful  here, 
and  also  suspensions  of  bismuth  and  solutions  of  nitrate  of  silver 
1 :  1000.  In  hypersecretion  the  same  solutions  as  in  hyperacidity 
are  applicable ;  but  in  addition  to  these  we  have  employed  tannigen,. 


MINERAL   SPRINGS.  315 

four  grams  to  one  liter,  rendered  soluble  by  bicarbonate  of  sodium. 
The  substances  applicable  in  gastric  fermentation  have  been  re- 
corded in  the  chapter  on  Motor  Insufficiency. 


CHAPTER  V. 
MINERAL  SPRINGS. 


The  Uses  and  Abuses  of  Natural  Mineral  Waters  in  Diseases  of  the 

Digestive  Organs.^ 

With  such  a  wealth  of  valuable  mineral  springs  in  this  country 
it  is  difficult  to  understand  the  large  annual  exodus  of  Americans 
to  foreign  water  resorts.  We  fear  the  fault  rests  with  the  American 
physician,  not  the  American  waters.  Few  native  physicians  give 
to  the  selection  and  adaptation  of  proper  mineral  waters  the  con- 
sideration it  deserves;  whereas  in  German,  French,  and  English 
practice  this  forms  a  common  and  important  factor.  According  to 
Baruch,  even  American  doctors  resident  at  the  springs  do  not  insist 
upon  precision  in  proper  drinking,  diet,  hydrotherapy,  or  exercise. 

The  surpassing  virtues  of  our  American  mineral  waters  can  be 
attested  only  by  making  an  individualizing  selection  of  the  waters 
for  each  case,  after  establishing  the  diagnosis. 

Too  much  empiricism,  too  much  fashion  and  sport,  too  much 
alcohol,  and  not  sufficient  peace  and  quiet  of  mind  exhibit  them- 
selves at  our  American  springs. 

Without  a  diagnosis — not  to  speak  of  test-meals — we  have  known 
of  numerous  instances  where  the  waters  of  springs  were  ordered. 
Systematic  mineral- water  treatment  should  be  recommended  only 
after  the  institution  of  careful  chemical  and  physical  examinations. 

In  reference  to  the  abuse  of  mineral  waters,  we  limit  ourselves 
to  their  misuse  in  gastric  diseases.  We  would  exclude,  first,  all 
cases  of  motor  insufficiency  of  any  kind,  whether  of  the  simple  atonic 
or  the  stenotic  form,  whether  with  pronounced  dilatation  or  not, 

*  In  the  preparation  of  this  chapter  we  have  availed  ourselves  of  the  Analyses  of  the 
Mineral  Springs  of  the  United  Slates  as  given  in  the  records  of  the  Department  of  the 
Interior  (Agriculture),  Washington,  D.  C.  ;  and  in  the  description  of  the  physiological 
•effects  of  the  various  springs  we  have  followed  the  works  of  Flechsig,  S.  Baruch,  Lud- 
wig,  and  G.  Thompson  in  reference  to  waters  with  which  we  have  no  personal  experience. 


3l6  MINKRAL   SPRINGS. 

because  we  know  that  water  is  not  absorbed  from  the  stomach,  and 
hence  can  only  aggravate  (by  its  weight)  the  myasthenia  and  dila- 
tation. Where,  however,  the  various  saline  and  alkaline  waters  can 
be  readily  obtained,  they  serve  admirably  for  lavage.  The  sodium 
chlorid  spring-water  is  beneficial  in  sub-  or  anacidity,  and  the  alka- 
line waters  whenever  hyperchylia  is  associated  with  dilatation. 

In  neoplasms  of  the  stomach,  particularly  in  carcinoma,  mineral- 
water  treatment  is  harmful.  For  ulcer,  the  Carlsbad  springs  have 
been  much  lauded  by  Leube  and  others ;  but  we  coincide  with  Ewald 
in  the  opinion  that  the  same  or  perhaps  more  rapid  effects  would 
have  been  obtained  in  such  cases,  had  patients  taken  the  rest  cure 
at  home.  Rest,  diet,  and  effective  local  treatment  are  the  things 
most  needed,  and  these  can  be  obtained  much  more  readily  at  home 
than  elsewhere.  For,  after  all,  as  far  as  gastric  sufferers  are  con- 
cerned, the  most  important  things,  even  at  the  springs,  are  rest  to 
body  and  stomach  in  particular,  diet,  suitable  food,  good  cooking,  etc. 

In  acute  gastritis  mineral  waters  are  useless.  There  remain  still 
to  be  considered  the  neuroses  of  secretion  and  motility.  All  secre- 
tory neuroses  are,  more  or  less,  indications  for  mineral-water  treat- 
ment, particularly  those  in  which  an  excessive  amount  of  HCl  is 
formed,  with  which  the  alkaline  waters  combine,  at  the  same  time 
exerting  a  very  desirable  astringent  effect  on  the  mucosa ;  for  these, 
such  waters  as  the  Saratoga  Vichy  are  applicable.  In  achylia  of 
nervous  origin  the  saline  waters  might  rationally  be  tried;  but 
where  the  glandular  elements  are  destroyed  they  can  not  restore 
the  secretion,  although  they  may  aid  in  dissolving  mucus  and  keep- 
ing the  membrane  cleaner  than  otherwise.  In  the  motor  neuroses, 
if  dependent  upon  hyperchylia  or  hypersecretion,  the  alkaline  waters 
may  benefit  by  removing  the  causes,  as  stated  above ;  but  in  insuffi- 
ciency of  the  pylorus  and  cardia  we  have  neither  heard  of  nor  seen 
improvement. 

The  proper  field  for  these  waters  is  undoubtedly  chronic  gastritis. 
With  their  judicious  use  much  good  can  be  effected.  It  should  not 
be  overlooked,  however,  that  there  may  be  a  chronic  gastritis  with 
normal  or  excessive  acidity;  here  the  alkaline  waters  are  to  be  pre- 
ferred to  the  salines.  In  chronic  gastritis  with  achylia  only  salines 
of  mild  concentration  are  useful;  for  the  powerful  saline  (NaCl) 
waters,  such  as  Carlsbad  (Miihlbrunnen),  may  undoubtedly  cause  an 
injurious,  alkaline,  irritative  transudate  from  the  mucosa  if  retained 
in  the  stomach. 


INDICATIONS   FOR   THE   USE   OF   MINERAL  WATERS.  317 

In  chronic  gastritis  the  still  or  the  carbonated  saline  waters  un- 
doubtedly are  beneficial,  by  their  stimulating  effect  on  the  secretions. 
Gastric  sufferers  should  drink  their  spring- water  preferably  warm. 
Cold  spring- water  should  be  rendered  tepid  by  the  addition  of  warmed 
water  from  the  same  spring.  All  waters  which  are  to  act  on  the 
stomach  are  tolerated  better  warm  than  cold. 

In  uncomplicated  hyperacidity  and  hypersecretion  the  alkaline  or 
the  mixed  alkaline  saline  springs  are  beneficial.  In  this  country  the 
Saratoga  Vichy  is  the  most  available.  Alkaline  waters  also  benefit 
peptic  ulcer  cases  when  there  have  been  no  hemorrhages  for  some 
time,  because  they  neutralize  the  acid  excess  and  actually  lessen  the 
activity  of  secretion.  Waters  containing  sodium  sulphate  are  applic- 
able to  the  treatment  of  secondary  gastritis. 

According  to  Stille  and  Maisch  there  are,  indeed,  two  classes  of 
patients  who  require  the  use  of  very  different  mineral  waters.  The 
first  is  composed  of  that  large  body  of  invalids  in  whom  there  exists 
no  organic  change  of  structure,  but  whose  functions  are  merely 
weakened  or  clogged  by  the  strain  of  business,  the  exhaustion  of 
pleasure,  excesses  in  eating  or  drinking,  or,  in  this  country  especially, 
by  the  manifold  errors  committed  in  the  preparation  and  consump- 
tion of  food  and  the  disregard  of  hygienic  rules  in  their  habits  of 
living.  The  second  consists  of  that  smaller  but  still  numerous  class 
of  persons  who,  besides  being  more  or  less  injured  by  the  causes  of 
ill  health  just  enumerated,  have  been  affected  with  definite  diseases, 
and  especially  rheumatism,  gout,  calculous  disorders,  cutaneous 
eruptions,  scrofula,  syphilis,  diabetes,  paralysis,  uterine  disorders, 
etc.  Of  these  two  classes  the  former  is  benefited  most  by  a  visit  to 
the  less  mineralized  springs,  while  the  latter  requires  a  course  of 
active  medicinal  treatment  such  as  the  stronger  mineral  waters 
afford.  In  both  classes  of  patients,  but  particularly  in  the  first,  the 
action  of  the  waters  is  only  one  out  of  many  influences  that  combine 
to  restore  their  health.  Toward  that  end  a  total  change  of  habit  is 
one  of  the  most  influential  agencies  in  very  many  cases.  Escape 
from  the  anxieties  and  fatigue  of  business,  from  the  excitement  of 
fashionable  life,  the  mental  tension  of  political  and  professional 
pursuits,  the  worrying  annoyances  of  domestic  affairs,  endured,  per- 
haps, in  a  large  city,  with  all  its  enervating  social  duties,  its  Babel- 
like sounds,  and  its  polluted  atmosphere, — escape  from  these  alone 
ought  to  suflice  to  restore  the  disturbed  balance  of  health.  When 
we  consider  how  much  more  probable  must  this  result  become  when 


3l8  MINERAL  SPRINGS. 

fatigue,  anxiety,  contention,  wearisome  routine,  and  foul  air  are 
exchanged  for  repose  and  peace  in  the  midst  of  novel  scenes  and 
new  associates,  and  freedom  from  the  onerous  conventionalities 
of  fashionable  life,  different  apartments,  food,  and  occupation,  it 
may  even  seem  doubtful  whether,  after  all,  some  other  new  resi- 
dence would  not  profit  the  invalid  as  much  as  the  frequented  springs. 
But  there  are  two  reasons  against  this  conclusion :  the  one  is  that, 
with  many  persons,  relief  would  be  impossible  without  an  exercise 
of  the  faith  which  gives  potency  to  waters  as  well  as  to  other  remedial 
agents;  and  the  other  is  that  even  the  purest  of  these  waters,  sys- 
tematically used,  especially  in  conjunction  with  bathing  and  regular 
exercise,  do,  in  a  greater  or  less  degree,  depurate  the  system  through 
the  kidneys,  bowels,  and  skin,  and  by  a  gentle  but  sustained  action 
gradually  remove  effete  products  of  tissue-change  from  the  system 
and  free  the  organs  from  the  poisons  that  tainted  them.  Judiciously 
used  under  the  advice  of  a  competent  physician,  these  almost  neutral 
waters  and  the  milder  saline  springs  are  capable,  in  a  few  weeks,  of 
changing  the  languid,  indifferent,  pale,  and  feeble  invalid  into  the 
lively  and  energetic  leader  of  the  gay  crowd.  Such  rapid  trans- 
formations are  frequently  witnessed,  especially  at  the  hot  springs  of 
Virginia,  the  Bedford  springs.  Pa.,  at  some  of  the  Saratoga  springs 
(though  in  the  last-mentioned  place  routine  hygienic  treatment  be- 
comes more  difi&cult  because  of  numerous  side  temptations),  and 
certain  European  springs,  such  as  Wildbad,  Gastein,  and  Pfefifers, 
none  of  which  contains  any  considerable  proportion  of  mineral  in- 
gredients. But  these  waters,  whether  drunk  warm  or  cold,  if  they 
are  largely  used,  act  as  organic  purgatives,  and  increase  materially 
the  total  amounts  of  solids,  and  especially  of  urea,  excreted  with  the 
urine,  without  causing  the  debility  which  an  equal  discharge  from 
the  bowels  would  occasion. 

Alkaline  Waters. — The  chief  ingredients  of  these  waters  are 
the  alkaline  carbonates,  especially  the  carbonate  of  sodium.  They 
also  contain  varying  amounts  of  the  carbonates  of  lime,  magnesium, 
lithium,  sodium  chlorid,  etc.,  and  many  of  them  are  strongly  charged 
with  carbonic  acid  gas.  Although  it  is  probable  that  the  other 
saline  constituents  may  contribute  to  the  total  physiological  effects 
of  these  waters,  they  owe  their  main  therapeutic  activity  to  the 
alkaline  salts  they  contain.  The  temperature  of  these  springs  is  also 
a  point  worthy  of  consideration.  In  a  general  way  it  may  be  said 
that  the  physiological  action  of  these  waters  is  like  that  of  any  alka- 


ALKALINE   WATERS.  319 

line  salt,  plus  the  effect  produced  by  the  circulation  of  large  quan- 
tities of  water  in  the  system.  The  carbonate  of  sodium  neutralizes 
free  acids  or  fermentation  products  in  the  stomach,  whether  taken 
during  or  after  meals.  According  to  Brunton  and  Sidney  Ringer, 
the  stronger  alkaline  waters,  if  taken  before  meals,  increase  the  secre- 
tion of  gastric  juice.  This,  in  the  author's  experience,  is  doubtful. 
The  fact  is,  distilled  water  will  also  cause  a  secretion  of  gastric  juice 
in  the  normal  stomach,  but  will  not  neutralize  the  acid  thus  secreted, 
as  the  alkahne  waters  must  invariably  do.  This,  however,  is  not  an 
effective  way  of  treating  anacidity.  For  this  condition  the  treat- 
ment is  given  in  the  clinical  part.  The  carbonic  acid  set  free  by  the 
decomposition  of  the  carbonates  in  the  stomach  and  the  sodium 
chlorid  usually  present  in  these  waters  act  as  a  stimulant  to  the 
gastric  mucous  membrane,  promoting  secretion  and  counteracting 
any  disturbing  influence  exerted  by  the  carbonate.  The  free  carbonic 
acid  frequently  contained  in  waters  of  this  class,  by  its  stimulating 
effects  on  gastric  peristalsis,  accelerates  digestion,  and  thereby  in- 
creases the  desii^e  for  food. 

It  would  appear,  therefore,  that  the  alkaline  waters  have  a  wide 
range  of  usefulness.  They  seem  to  be  especially  indicated  in  gastric 
affections  in  which  there  is  an  excessive  production  of  hydrochloric 
acid,  as  in  acid  dyspepsia,  atony  of  the  gastric  mucous  membrane, 
and  gastric  ulcer.  In  all  catarrhal  conditions  of  the  stomach  they 
are  most  serviceable,  but  a  free  and  prolonged  use  lowers  the  nutri- 
tion, except  in  case  of  waters  containing  chlorid  of  sodium. 

The  names  of  a  few  of  the  more  important  Alkaline  Waters 
are  here  appended: 

Vichy,  in  France;  Ems  and  Fachingen,  in  Germany;  Saratoga 
Vichy  (rich  in  CO2),  New  York;  St.  Louis  Springs,  Michigan  (poor 
in  CO2);  Bethesda  Springs,  Wisconsin.  Other  sodium  chlorid 
waters,  containing  also  some  carbonates  and  CO2,  are:  Hathorn, 
Congress,  and  Kissengen  Springs,  in  Saratoga,  New  York ;  Homburg, 
Wiesbaden,  Kissingen,  and  Selters,  in  Germany;  Bourbonne,  in 
France. 

All  alkaline  waters  contain  more  or  less  carbon  dioxid,  and  their 
most  important  ingredients  are  the  alkaline  carbonates.  They  also 
contain  sodium  chlorid  and  sometimes  sodium  sulphate.  In  some, 
one  variety  of  salts,  in  others,  another  preponderates.  Generally 
speaking,  the  European  waters  are  richer  in  alkalies  than  are  the 
American. 


320 


MINSRAI,  SPRINGS. 


Alkaline  waters  are  useful  in  uric  acid  diathesis  and  lithemic  con- 
ditions, gout,  chronic  rheumatism,  obesity,  hepatic  engorgement, 
gall-stones,  hyperacidity,  gastric  ulcer,  and  catarrhs  of  the  mucous 
membranes,  especially  of  the  stomach,  respiratory  tract,  and  bladder. 

Alkaline  Sulphur  Waters.— Richfield  Springs,  Sharon  Springs, 
and  Avon  Springs,  in  New  York;  Greenbrier  White  Sulphur  Springs, 
in  West  Virginia;  Harrogate,  in  England;  Neuendorf  and  Meinberg, 
in  Germany;  Aix-la-Chapelle,  in  Rhenish  Prussia. 

Those  waters  containing  sulphureted  hydrogen  in  addition  to  other 
ingredients  are  used  moderately  in  gout,  chronic  rheumatism,  obesity, 
and  chronic  eczema.  They  are  often  supplemented  by  a  course  of 
chalybeate  waters. 


COMPARATIVE  CHART  ILLUSTRATIVE  OF  ALKALINE  WATERS.— 

{^Baruch.^ 


European. 

0 

NE  Pint  Contains: 

American. 

6 

ii 

U 

< 

ca 
.U 

0) 

3 

u 
<u 

a 

E 

Other  Prominent 
Constituents. 

Ojo  Caliente  Spring, 
New  Mexico,  .    . 

Vichy     (Grand 
Grible    Spring) , 
France,  .... 

Grs. 
26 

19 
II 

10 

7 

Cub.  in. 
14 

32 
48 

6 

I 

Fahr. 
105.8° 

100° 
50° 

50° 

115° 

50° 

Sodium  chlorid,  4  grs.; 
sodium  sulphate,  2 
grs.  ;  potassium  car- 
bonate, 2  grs. 

Sodium  chlorid,  4  grs.; 

Saratoga    Vichy 
Spring,  NewYork, 

St.     Louis     Spring, 
Michigan,         .    , 

Fachingen  Spring, 
Germany,  .    .    . 

Ems  (Kesselbrun- 
nen     Spring), 
Germany,  .    .    . 

sodium  sulphate,  I  gr. 
Sodium  chlorid,  4  grs.; 

calcium    carbonate,    2 

grs. 
Calcium  and  magnesmm 

carbonates,     17     grs.; 

sodium  and  potassium 

chlorids,  18  grs. 
Sodium  chlorid,   7  grs.; 

calcium    carbonate,    I 

Calcium  and  magnesium 

carbonates,     6     grs.  ; 
calcium     sulphate,     7 
grs. 

Alkaline  and  saline  purges  contain  a  high  percentage  of  sodium 
and  magnesium  sulphates.  These  waters  are  often  called  "bitter 
waters."  Such  are  Pullna,  in  Bohemia  (the  strongest  of  all  and  one 
of  the  oldest  known);  Carlsbad  (Sprudel),  in  Bohemia;  Marienbad 


SALINE  WATERS. 


321 


(Elreuzbrunnen),  in  Bohemia;  Friedrichshall,  in  Germany;  Franz 
Josef,  in  Austria ;  Kissingen  Bitter  Water,  in  Bavaria ;  Hunyadi  Janos, 
in  Hungary;  Rubinat  Condal  Spring  and  Villacabras,  in  Spain;  Crab 
Orchard  and  Estill  Springs,  in  Kentucky ;  Bedford  Springs,  in  Penn- 
sylvania; Epsom,  in  England;  some  of  the  Saratoga  waters.  These 
waters  are  useful  to  counteract  indiscretions  in  diet  and  congestion 
of  the  liver.  The  Rubinat  water  is  effective  and  possesses  the  ad- 
vantage of  being  less  disagreeable  than  many  of  the  others.  Villaca- 
bras is  a  Spanish  sodium  sulphate,  strongly  purgative  water,  obtained 
not  far  from  Madrid. 

These  waters  should  be  taken  either  very  cold  or  in  a  half-pint 
of  very  hot  water.  If  drunk  lukewarm,  their  taste  is  nauseous  and 
may  excite  emesis.  We  advise  that  these  powerful  waters  be  entirely 
avoided  where  there  is  any  distinct  organic  disease  of  the  stomach. 

Various  other  waters  are  the  Alum  Springs,  in  Virginia ;  Oak  Orchard 
Acid  Spring,  in  New  York;  Bourboule,  in  France,  which  contains 
arsenic.  Roncegno  water  is  a  ferruginous  arsenical  water  from  the 
Tyrolean  province  of  Trent. 

Saline  Waters. — This  class  may  be  conveniently  subdivided  into, 
first,  waters  containing  chiefly  the  chlorid  of  sodium;  and,  second, 
waters,  containing  large  quantities  of  the  sulphates  of  sodium  and 
magnesium — the  so-called  "bitter  waters"  of  German  authors. 


COMPARATIVE   CHART   ILLUSTRATIVE   OF   SALINE  WATERS.— 


European. 

• 

One  Pint  Contains: 

American. 

S-o" 

0  m 

V  at 

O.V-. 

h 

Other  Prominent 
Constituents. 

Ballston      Artesian 
Lithia  Well,  New 
York, 

Homburg    (Eliza- 
bethbrunnen), 
Germany,  .    ,    . 

Grs. 

79 
93 

52 
64 

Cub.  in. 

48 

53 

17 

47 

Fahr. 
50° 

155° 
47° 

Grains. 

Chlorids  of  calcium  and 
magnesium,  15  ;  cal- 
cium carbonate,  II. 

Magnesium  and  calcium 
carbonate,  34  ;  potas- 
sium chlorid, 4;  lithium 
carbonate,  0.7. 

Chlorid  of  potassium,  I; 
calcium  carbonate,  3. 

Calcium  and  magnesium 

Hathorn,  Spring, 
Saratoga,  New 
York, 

Wiesbaden  (Koch- 
brunnen),     Ger- 
many,    .... 

carbonates,  28. 

322 


MINSRAIv  SPRINGS. 


Comparative  Chart  Illustrative  of  Saline  Waters. — {Continued.' 


American. 


Congress  Spring, 
Saratoga,  New 
York 


Kissengen  Spring, 
Saratoga,  New 
York, 


Saratoga     Seltzer 
Spring,  NewYork, 


European. 


Bourbonne  (Fon- 
taine Chaude), 
France,  .    .    .    . 


Kissingen     (Rak- 
oczi),  Germany, 


Selters,  Germany, 


One  Pint  Contains: 


O  J3 

t/3U 


Grs. 
46 

50 
44 
42 

17 

17 


cO 


Cub.  in. 

49 
42 

45 
30 


a.  I-. 
E5 


Fahr. 

149° 
52° 
51° 
40° 

62° 
50° 


Other  Prominent 
Constituents. 


Grains. 


Calcium  chlorid,  5  ;  cal- 
cium sulphate,  6. 

Calcium  and  magnesium 
carbonates,  21;  sodium 
bromid,  1. 06. 

Potassium  chlorid,  2 ; 
calcium  carbonate,  8. 

Calcium  and  magnesium 
carbonates,  26;  sodium 
carbonate,  8  ;  lithium 
carbonate,  0.64. 

Sodium  carbonate,  6. 

Sod'um  carbonate,  2;  cal- 
cium and  magnesium 
carbonates,  ID. 


The  Sodium  Chlorid  "Waters. — These  waters  contain,  besides 
large  quantities  of  sodium  chlorid,  a  certain  proportion  of  other 
chlorids,  especially  those  of  lime  and  magnesium,  and  small  amounts 
of  alkaline  and  earthy  sulphates  and  carbonates,  iodids  and  bromids. 
Carbonate  of  iron  is  sometimes  present  in  considerable  quantity. 
The  gases  consist  for  the  most  part  of  carbonic  acid,  which  renders 
the  water  more  agreeable  to  the  palate  and  more  readily  absorbed. 
Some  of  these  waters  are  heavily  charged  with  sulphureted  hydrogen. 
They  occur  both  as  cold  and  thermal  springs,  and  may  be  utilized 
both  for  drinking  and  bathing  purposes. 

The  physiological  action  of  these  waters  is  chiefly  attributable 
to  the  presence  of  sodium  chlorid.  This  salt,  as  is  well  known,  has 
a  stimulating  effect  upon  all  the  mucous  membranes  of  the  body, 
especially  that  of  the  gastro-intestinal  tract.  In  the  stomach  it  dis- 
solves the  mucus,  increases  the  secretion  of  gastric  juice,  thereby 
promotes  the  digestion  of  albuminous  substances,  and  excites  peri- 
stalsis. In  the  intestines  it  stimulates  the  flow  of  pancreatic  juice 
and  bile,  and,  owing  to  its  well-known  influence  on  the  process  of 
osmosis,  promotes  the  absorption  of  food.  Intestinal  peristalsis  is 
also  increased,  and,  if  the  sodium  chlorid  is  present  in  large  quantity, 


BITTER   OR   PURGATIVE   WATERS.  323 

the  water  may,  in  its  effects,  be  laxative  and  even  purgative.  Some 
authors  have  regarded  this  purgative  action  as  representing  the 
chief  therapeutic  virtues  of  these  waters,  but,  according  to  Flechsig, 
it  is  subordinate  in  importance  to  the  effect  of  the  sodium  chlorid  on 
the  blood.  He  states  that  this  salt  exerts  considerable  influence  on 
the  process  of  tissue  metabolism,  augmenting  the  metamorphosis  of 
nitrogenous  matters  and  increasing  the  oxidation  of  albuminous 
substances,  as  is  shown  by  the  increased  quantity  of  solids  in  the 
urine.  The  iodids  and  bromids  contained  in  some  of  these  waters 
are  usually  present  in  such  very  minute  amounts  that  it  is  doubtful 
whether  they  contribute  to  their  therapeutic  action ;  at  any  rate,  it  is 
impossible  to  separate  their  effects  from  those  of  the  sodium  chlorid. 

The  therapeutic  indications  of  sodium  chlorid  waters,  as  based 
upon  their  physiological  action,  are  sufficiently  obvious.  Their 
stimulating  effects  upon  the  mucous  membranes  have  been  utilized 
in  the  treatment  of  catarrhal  processes,  especially  in  the  stomach, 
duodenum,  and  bile-ducts;  and  in  chronic  intestinal  catarrh  asso- 
ciated with  constipation,  their  use  has  been  highly  commended. 

Bitter  or  Purgative  Waters. — This  name  has  been  applied  to 
waters  characterized  by  a  high  percentage  of  the  sulphates  of  sodium 
and  magnesium.  They  also  contain  considerable  quantities  of  the 
sulphates  of  lime,  and  the  carbonates  of  lime  and  magnesium,  though 
rarely  small  amounts  of  carbonic  acid  gas.  Carbonate  of  sodium, 
however,  is  seldom,  if  ever,  found  in  them. 

The  chief  physiological  action  of  these  waters  is  comprised  in 
the  stimulating  effect  which  they  exert  upon  the  mucous  membranes 
of  the  gastro-intestinal  tract.  They  give  rise  to  a  profuse  watery 
secretion  of  a  serous,  or  even  mucous,  character,  and  thus  act  as 
purgatives.  If  taken  in  large  quantities,  they  frequently  produce 
gastric  and  intestinal  disturbances,  and  their  protracted  use  is  apt 
to  be  followed  by  atony  of  the  intestines  and  intestinal  catarrh.  It 
is  as  yet  a  matter  of  speculation  whether  this  purgative  action  is  due 
to  the  increased  exudation  of  fluids,  or  whether  it  results  from  the 
stimulation  of  intestinal  peristalsis,  as  is  assumed  by  Flechsig  and 
others.  Owing  to  the  increased  peristalsis,  the  passage  of  food 
through  the  intestines  is  accelerated;  and  in  consequence  of  the 
diminished  absorption  of  nutriments  engendered  by  this,  a  loss  of 
weight  and  disappearance  of  the  fatty  tissue  result. 

It  follows  from  the  above  considerations  that  the  use  of  these 
waters  is  restricted  to  cases  in  which  we  desire  to  stimulate  the  in- 


324 


MINERAIv   SPRINGS. 


testinal  secretions,  as  in  chronic  constipation  occurring  in  plethoric 
persons,  engorgements  of  the  abdominal  and  pelvic  viscera,  hemor- 
rhoids, etc.  They  also  prove  serviceable  in  cases  of  obesity,  as  part 
of  a  treatment  of  denutrition.  On  the  other  hand,  their  use  is  contra- 
indicated  in  anemic  persons,  and  where  there  is  great  irritability 
of  the  stomach  and  intestines,  with  a  tendency  to  diarrhea. 


COMPARATIVE    CHART  ILLUSTRATIVE  OF  BITTER  AND   PURGATIVE 

WATERS.  —{Barttch. ) 


Crab  Orchard, 
Foley's  Spring, 
Kentucky,    .    . 


Estill's  Springs, 
Irvine  Springs, 
Kentucky,    .    . 


Bedford  Springs, 
Pennsylvania,  . 


Harr  odsbur  g 
Spring,  Saloon 
Spring,  Ken- 
tucky,     .    .    . 


Piillna,  Bohemia, 


Friedrichshall, 
Germany,    . 


Carlsbad  (Spru- 
del),  Bohemia, 


Marienbad 

Kreutzbrunnen) 

Bohemia,    .    . 


One  Pint  Contains: 


E5 


Grs. 
124 

7 
41 


19 


36 


Grs. 
93 

25 
39 

32 


28 


U<; 


Cub.  in, 


9 
15 


Fahr. 


46° 


162° 

58° 
53° 


Other  Prominent 
Constituents. 


Chlorid  of  magne- 
sium, 16  grs. ;  mag- 
nesium carbonate, 
6  grs. 

Calcic  carbonate,  7 
grs.;  potassium  sul- 
phate, I  gr. 

Sodium  chlorid,  67 
grs. ;  magnesium 
chlorid,  31  grs.  ; 
calcic  sulphate,  il 
grs. 

Calcic  carbonate,  4 
grs.;  sodium  chlo- 
rid, 2  grs. 

Sodium  carbonate,  9 
grs. ;  sodium  chlo- 
rid, 8  grs. 

Chlorid  of  sodium,  I 
gr. ;  calcium  sul- 
phate, 2  grs. 

Sodium  carbonate,  8 
grs.;  sodium  chlo- 
rid, 1 1  grs. 

Calcic  sulphate,  10 
grs.;  sodium  chlo- 
rid, I  gr. 


American  waters  of  this  class  are  somewhat  weaker  in  sulphates 
of  sodium  and  magnesium  than  the  European,  but  the  quantity  of 
purgative  salts  present  in  the  former  is  quite  sufficient  to  produce 
active  therapeutic  effects.  All  these  waters  contain  a  considerable 
amount  of  sodium  chlorid,  which  contributes  essentially  to  their 
physiological  action. 


SUIvPHURETED    WATERS.  325 

The  Bedford  Spring  (Pa.)  water  is  especially  to  be  recommended 
on  account  of  its  mildness.  It  is,  in  our  opinion,  of  no  advantage 
when  spring-waters  possess  an  excessively  large  percentage  of  drastic 
salts.  In  a  concentrated  solution  magnesium  chlorid  acts  as  a  cellular 
poison  on  the  superficial  gastric  and  intestinal  epithelium  when  used 
for  weeks.  Bedford  Mineral  Magnesia  Spring  has  also  a  mildly 
diuretic  effect;  its  laxative  effect  is  not  experienced  until  at  least 
500  c.c.  are  taken  in  twelve  hours. 

Sulphurated  Waters. — The  constituent  imparting  to  these  waters 
their  distinguishing  characteristic  is  the  sulphureted  hydrogen 
which  they  contain  in  greater  or  lesser  amount.  With  this  gas  we 
find  associated  a  varying  quantity  of  sulphur  combinations,  such  as 
the  sulphids  of  potassium,  sodium,  calcium,  and  magnesium.  They 
also  contain  the  alkaline  and  earthy  sulphates  and  carbonates,  the 
chlorid  of  sodium,  and  the  sulphates  and  carbonates  of  iron;  and 
these  are  frequently  present  in  large  quantities,  and  certainly  play 
a  not  unimportant  part  in  the  therapeutic  action  of  these  waters. 
According  to  Daland,  "a  sulphur  spring  of  moderate  strength  con- 
tains not  less  than  twelve  cubic  inches  of  sulphureted  hydrogen  in 
the  gallon,  though  many  springs  contain  so  small  an  amount  that 
therapeutically  they  are  inert,  and  the  good  effects  observed  are  due 
to  the  influence  of  the  increased  use  of  water,  change  of  scene  and 
climate,  cessation  of  work,  regular  meals,  good  hygiene,  and  hope — all 
of  which  contribute  strongly  to  restore  health  at  all  springs."  Many 
of  the  sulphur  waters  are  thermal,  and  are  chiefly  employed  in  baths. 

Regarding  the  physiological  action  of  sulphur  waters  on  the  sys- 
tem, nothing  positive  can  be  said.  Various  plausible  theories  have 
been  proposed  to  account  for  their  curative  effects  in  the  diseases  for 
which  they  are  employed.  It  is  claimed  that  their  chief  action  is  ex- 
erted on  the  intestinal  canal,  where  they  stimulate  the  functions  of  the 
glands,  augmenting  secretion  and  producing  laxative  effects.  When 
administered  for  prolonged  periods  they  give  rise  to  gastro-intestinal 
disorders  and  exert  a  debilitating  influence  upon  the  blood,  heart, 
and  lungs,  as  evidenced  by  anemia,  cardiac  weakness,  etc.  Accord- 
ing to  Leichtenstern,  the  sulphureted  hydrogen  absorbed  into  the 
blood  is  rapidly  converted  into  sulphuric  acid,  and  is  therefore 
devoid  of  any  specific  effect,  unless  present  in  very  large  amounts. 
On  the  other  hand.  Stiff t  concludes  that  the  sulphureted  hydrogen 
has  a  specific  excitant  action  upon  the  sensitive  fibers  of  the  pul- 
monary branches  of  the  pneumogastric  and  upon  the  respiratory, 
cardiac,   and  vasomotor  centers,   its  prolonged  use  giving  rise  to 


326 


MINERAL  SPRINGS. 


paralysis  from  overstimulation.  In  this  way  he  explains  the  action  of 
the  sulphur  waters  upon  the  respiratory  and  circulatory  systems,  upon 
tissue-metabolism,  and  upon  the  secretory  and  excretory  functions. 

These  waters  have  been  administered  internally  in  passive  con- 
gestion of  the  abdominal  and  pelvic  viscera,  especially  in  plethoric 
persons;  in  enlargements  of  the  liver  and  spleen;  hemorrhoids; 
chronic  intestinal  catarrh;  and  chronic  poisoning  by  metals.  In  the 
form  of  baths  they  have  been  recommended  in  gout  and  chronic 
rheumatism,  but  their  curative  effect  in  these  cases  is  attributable 
to  the  elevated  temperature  of  the  waters  rather  than  to  any  specific 
action  of  the  sulphureted  hydrogen  or  other  constituents.  At  many 
baths  the  internal  or  local  use  of  the  waters  is  combined  with  in- 
halation of  the  gases  or  of  the  nebulized  waters ;  and  this  method  has 
been  found  useful  in  the  treatment  of  chronic  catarrhs  of  the  pharynx, 
larynx,  and  bronchi.  Sulphureted  waters  are,  in  our  estimation, 
worthless  as  a  therapeutic  agent  in  gastro-intestinal  diseases. 

The  following  chart  illustrates  the  superiority  of  the  sulphur 
waters  of  America : 


COMPARATIVE  CHART  ILLUSTRATIVE  OF  SULPHURETED 
WATERS.  — {'Baruck.) 


American. 


Sandwich    Spring, 
Ontario,  Canada,  . 


Sharon  Spring,  White 
Sulphur  Spring, 
New  York,     .    .    . 


Paroquet  Spring, 
Kentucky,  .    .    .    . 

Salt  Sulphur  Spring, 
lodin  Spring,  W. 
Virginia,      ,    .    .    . 


European. 


Neundorf,  Germany, 


Aix-le-Bains, 
France 


Harrogate,       Eng' 
land,      


Meinberg,  Germany, 


(fi* 


Cub. 
in. 

1.28 
4.72 


0.82 


0.53 


3-75 
0.61 


2-39 


One  Pint  Contains  : 


Grs. 

0.55 


0.28 


1-54 


0.67 


Fahr. 

53° 

52° 

108° 


Other  Prominent 

Constituents. 


Calcium    and     magnesium 

sulphates,  10  grs. 
Chlorid  of  magnesium,  19 

grs.  ;    calcium  sulphate. 

Calcium  carbonate,  I  gr. 


Calcium  and  magnesium 
sulphates,  24  grs. 

Sodium  chlorid,  86  grs.  ; 
potassium  and  magne- 
sium chlorids,  10  grs. 

Sodium  chlorid,  39  grs. 

Sodium  sulphate,  6  grs. 


Sodium    sulphate,    3  grs.  ; 
calcium  sulphate,  8  grs. 


CHALYBEATE    WATERS.  327 

Sulphureted  waters  are  abundantly  represented  in  the  United 
States.  In  Virginia  they  are  particularly  well  represented — vide 
Jordan's  White  Sulphur  Springs,  Frederick  County;  Greenbrier 
White  Sulphur  Springs,  Roanoke  Red  Sulphur  Springs,  Yellow 
Sulphur  Springs,  Montgomery  County,  Va.,  and  many  others  in 
other  States.  There  is  certainly  no  necessity  for  traveling  to  Aachen- 
Baden  (near  Vienna),  Leuk,  or  Weilbach  to  use  waters  of  this  type. 

Chalybeate  Waters. — A  large  number  of  mineral  springs  con- 
tain the  salts  of  iron,  but  the  quantity  present  is  frequently  so  small 
as  to  be  practically  devoid  of  therapeutic  effects.  In  the  class  under 
consideration  only  waters  containing  a  sufficient  quantity  of  chaly- 
beates  to  be  of  value  in  the  treatment  of  disease  will  be  mentioned. 

Iron  salts  usually  occur  in  the  form  of  the  carbonate  or  sulphate. 
Other  constituents,  which  are  sometimes  present  in  large  amounts, 
are  the  alkaline  carbonates  and  sulphates,  the  earthy  carbonates, 
sodium  chlorid,  alum,  and  sulphuric  acid.  Alum  often  exists  in  con- 
siderable quantities,  especially  in  the  chalybeate  springs  of  Virginia. 

Chalybeate  waters  containing  the  carbonate  of  iron  are  clear,  odor- 
less, have  a  slight  inky  taste,  and  are  highly  charged  with  carbonic 
acid  gas,  which  renders  them  palatable.  They  are  chiefly  employed 
for  drinking  purposes.  The  sulphate-of-iron  waters  have  a  marked 
astringent  taste,  which  sometimes  proves  an  objection  to  their  use. 
This  astringency  may  be  decidedly  increased  by  the  presence  of  alum. 

The  physiological  action  of  chalybeate  waters  is  essentially  similar 
to  that  of  all  iron  compounds;  they  promote  constructive  meta- 
morphosis, increasing  the  number  of  red  corpuscles  in  the  blood  and 
stimulating  all  the  body-functions.  For  internal  use  the  waters 
containing  the  carbonate  of  iron  are  preferable,  since  they  are  less 
apt  to  disturb  the  stomacli,  and  are  more  easily  assimilated,  owing 
to  the  carbonic  acid  gas  present.  According  to  the  character  of  the 
case,  it  may  be  necessary  to  select  an  iron  water  containing  alkalies, 
sodium  chlorid,  sulphate  of  sodium  and  magnesia,  or  alum. 

The  chalybeate  waters  have  been  recommended  in  anemia,  chlorosis, 
and  all  conditions  attended  with  anemia,  such  as  hysteria  and  neuras- 
thenia ;  chronic  endometritis,  dysmenorrhea,  amenorrhea,  chronic  gon- 
orrhea, and  spermatorrhea ;  chronic  affections  of  the  kidneys,  diabetes 
mellitus,  chronic  gastritis,  nervous  dyspepsia,  chronic  diarrhea,  etc. 

Among  the  iron  and  alum  springs,  Bedford  Alum  Spring  has  been 
found  remarkably  efficacious  by  Baruch  in  chronic  diarrhea,  which 
had  resisted  both  private  and  hospital  treatment. 


32  8 


MINERAL  SPRINGS. 


The  contraindications  to  their  use,  as  given  by  Flechsig,  com- 
prise all  febrile  and  congestive  conditions  and  advanced  organic 
diseases  of  the  lungs,  liver,  and  kidneys.  The  sulphate-of-iron 
waters  are  excellent  astringents  and  disinfectants,  and  have  been 
highly  recommended  in  chronic  diarrhea,  gastric  ulcer,  etc. 

The  following  chart*  illustrates  the  superior  quality  of  some 
American  chalybeate  springs : 


CHALYBEATE  WATERS.— {BarucA.) 


American. 


European. 


Church    Hill    Alum 
Springs,  Virginia, 


Rock  Enon  Springs, 
Virginia,    .    .    .    . 


Vichy  Springs,  New 
Almaden,  Cal.,    . 


Estill  Springs,  Ken- 
tucky,     


Brighton,    England, 


Spa    (Buhon),    Bel- 
gium,     


Schwalbach  (Stahl- 
brunnen),  Ger- 
many,    


St.  Moritz  (Grande 
Source),  Switzer- 
land,      


One  Pint  Contains  : 


1.80 
19.8 


0.67 
1.78 


0.46 


0.60 


0.17 


0.23 


U^ 


71.6 


50.2 


29.8 


39-2 


4-15 


Other  Prominent 
Constituents. 


Calcium  sulphate,  4  grs. 

Magnesium  and  calcium 
sulphates,  22  grs.;  alu- 
minium sulphate,  9  grs. 

Small  amounts  of  calcium 
carbonate  and  alumina. 

Calcium  and  magnesium 
sulphates,  2  grs.  ;  cal- 
cium and  sodium  carbon- 
ates, alumina. 

Calcium  carbonate,  I  gr.  ; 
manganese  carbonate, 
o.  10  gr. 

Sodium  carbonate,  1 7  grs.  ; 
calcium  carbonate,  3  grs.; 
magnesium  sulphate,  I 
gr.  ;  sodium  chlorid,  4 
grs. 

Sodium  carbonate,  I  gr.  ; 
calcium  carbonate,  6 
grs.  ;    sodium   sulphate. 

Calcium  carbonate,  I  gr. ; 
magnesium  sulphate,    I 

gr- 


*  These  charts  make  no  claim  to  completeness.  Boas  has  suggested  a  more  extensive 
enumeration  of  the  German  chalybeate  springs  in  this  book  (see  Review  on  Hemmeter's 
"  Diseases  of  the  Stomach,"  "  Deutsche  med.  Wochenschrift,"  April  14,  1898,  No.  15  ; 
"  Literaturbeilage,"  No.  10,  p.  58).  This,  however,  can  not  fairly  be  considered 
within  the  range  of  our  work.  We  can  not  even  do  justice  to  our  native  mineral  springs. 
For  fuller  information  we  must  refer  to  the  works  quoted  in  the  beginning  of  this 
chapter. 


INDICATIONS    FOR   THE    USE    OF    ACIDULOUS    WATERS.  329 

Acidulous  Waters. — These  waters  owe  their  therapeutic  prop- 
erties to  the  large  quantity  of  carbonic  acid  gas  they  contain,  the 
solid  constituents  being  present  only  in  small  amounts.  As  has 
been  stated,  many  alkaline  and  saline  waters  contain  considerable 
quantities  of  COo ;  but  its  effects,  whatever  they  may  be,  are  com- 
pletely subdued  by  those  of  the  mineral  ingredients.  In  the  acid- 
ulous waters,  however,  the  carbon  dioxid  is  the  chief  therapeutic 
agent,  and  for  this  reason  it  becomes  necessary  to  discuss  them  as 
a  separate  class  of  mineral  waters. 

The  physiological  action  of  carbonated  waters  is  comprised  in  a 
gentle  stimulative  effect  upon  the  mucous  membrane  of  the  stomach, 
promoting  peristalsis,  and  thereby  a  more  rapid  evacuation  of  its 
contents.  The  pulse  and  respiration  are  said  to  be  slightly  accel- 
erated, and  a  large  quantity  of  urine  is  excreted.  It  seems,  however, 
that  this  diuretic  effect  is  not  attributable  to  the  carbonic  acid  gas, 
as  is  assumed  by  some  authors,  but  rather  to  the  large  quantities  of 
water  which  the  patient  is  able  to  imbibe  without  distress,  for  the 
quantity  of  the  gas  absorbed  into  the  blood  through  the  walls  of  the 
stomach  is  certainly  too  small  to  produce  systemic  effects. 

The  acidulous  waters  have  been  chiefly  recommended  in  gastric 
disorders,  especially  those  of  neurotic  origin;  and,  owing  to  their 
agreeable  taste,  they  form  excellent  table  waters.  They  relieve 
nausea,  increase  the  appetite,  and  aid  digestion  by  stimulating  the 
secretion  of  HCl.  On  account  of  their  stimulating  effect  upon  the 
peripheral  cutaneous  nervous  system,  they  have  also  been  employed 
as  baths. 


CHAPTER  VI. 
IMPORTANT  MEDICINAL  AGENTS  IN  GASTRIC  THERAPY. 

HCl  is  given  in  the  absence  or  diminution  of  the  normal  secretion 
mainly  for  three  purposes:  (i)  To  supplement  gastric  proteolysis; 
(2)  to  act  as  an  antiseptic;  (3)  as  a  tonic  and  stomachic. 

To  these  effects,  which  we  have  in  mind  in  supplying  HCl,  may 
be  added  its  influence  as  a  regulator  of  the  gastric  peristalsis;  and 
that  it  brings  the  insoluble  calcium  and  magnesium  salts  of  the  in- 


330         IMPORTANT   MEDICINAL   AGENTS    IN    GASTRIC    THERAPY. 

gesta  into  solution;  in  fact,  all  of  the  objects  and  functions  that  are 
recognized  as  physiological  to  the  HCl  (see  p.  49)  may  be  at  least 
partially  accomplished  by  supplying  it  in  sufficient  quantity. 

The  HCl  deficit — i.  e.,  the  amount  of  decinormal  HCl  solution 
that  must  be  added  until  the  reaction  of  the  chyme  shows  free  HCl 
— should  be  determined  when  the  reactions  for  free  HCl  turn  out 
negative.  In  one  case  the  deficit  ma}^  be  very  slight,  in  another 
very  considerable.  Slight  deficits  generally  yield  readily  to  treat- 
ment by  diet  and  lavage,  often  without  administration  of  HCl ;  large 
deficits  may  be  a  sign  of  atrophy  and  never  yield  to  HCl  therapy, 
no  matter  how  much  is  given.  But  the  question  arises.  Can  it  be 
supplied  in  sufficient  quantity?  The  simple  presence  of  free  HCl 
does  not  contraindicate  the  administration  of  the  acid.  Positive 
reaction  to  Congo  paper  and  phloroglucin-vanillin  indicates,  it  is 
true,  that  HCl  is  secreted  in  excess  of  what  is  required  to  combine 
with  the  food.  In  healthy  digestion  it  is  always  found  that  this  ex- 
cess amounts  on  the  average  to  30  c.c.  of  a  decinormal  solution  of 
NaOH  after  an  Ewald  test-meal  (in  Baltimore) ;  and  it  seems  to  be 
what  is  necessary  or  advantageous,  not  for  digestive  purposes  (for 
even  with  a  large  excess  of  HCl  it  is  not  the  rule  for  all  the  proteid 
matter  to  be  digested  in  the  stomach),  but  for  destroying  the  ex- 
uberance of  micro-organisms  swallowed  with  the  food.  The  fre- 
quently quoted  cases  without  any  gastric  secretion  whatever  who 
succeed  in  maintaining  their  nitrogen  equilibrium, — and  we  have 
seen  many  such, — and  the  experiment  with  the  dog  (Kaiser  and 
Czerny)  whose  weight  was  kept  up  although  the  largest  portion  of 
the  stomach  was  removed,  and  the  total  extirpations  of  the  stomach 
by  Schlatter,  Brigham,  and  others,  constitute  but  a  weak  argument 
against  the  therapy  of  HCl.  For  although  such  patients  manage 
to  get  along  fairly  well,  it  is  only  under  the  most  careful  diet  and 
by  taking  very  little  exercise  that  they  maintain  their  health.  Per- 
manent and  perfect  health  with  total  absence  of  gastric  secretion  is 
rarely  observed,  except  in  those  who  are  able  to  rest  much  and  have 
their  food  prepared  with  great  care.  These  facts  must  not  be  over- 
looked in  the  work  of  von  Noorden  ("Ueber  die  Ausniitzung  der 
Nahrung  bei  Magenkranken, "  "Zeitschrift  f.  klin.  Med.,"  1S90,  Bd. 
xvii),  which  demonstrated  that  absolute  and  permanent  deficienc}^ 
of  gastric  juice  may  be  accompanied  by  perfect  health.  This  health 
is  perfect  under  the  conditions  mentioned,  but  when  they  are  taxed 
by  work  or  the  diet  is  not  the  usual  one,  suffering  becomes  manifest. 


LOSS    OF    HYDROCHLORIC    ACID   SECRETION.  33 1 

If  achylia  gastrica  could  really  exist  without  any  subjective  or  objec- 
tive disturbance,  how  is  it  that  so  many  of  these  patients  consult 
the  stomach  specialists  and  are  reported  by  them  in  literature? 
When  we  must  work  for  our  living  and  can  not  have  the  benefit  of 
the  dietetic  kitchen  at  all  times,  we  must  have  an  active  gastric  juice 
to  partially,  at  least,  disinfect  and  dissolve  our  food,  and  a  person 
who  secretes  no  gastric  juice  is  or  soon  becomes  a  patient.  In  a 
recent  article  on  Achylia  Gastrica  by  F.  Martins  and  O.  Lubarsch 
(published  by  T.  Deuticke,  Leipzig,  1897),  the  authors  arrive  at  the 
conclusion  that  neither  simple  achylia  nor  that  dependent  upon 
atrophy  of  the  mucosa  (anadenia)  can  bring  about  severe  anemic  or 
cachectic  conditions  unless  motor  insufficiency,  atrophy  of  the 
intestinal  mucosa,  or  general  diseases  (tuberculosis,  lues,  infections, 
etc.)  are  added.  Even  if  this  is  true,  generally  speaking  it  does  not 
disprove  the  statement  that  absence  of  HCl  in  the  gastric  secretion 
compels  the  individual  to  lead  the  life  of  a  patient.  But  over  and 
beyond  this,  Flint  {loc.  cit.),  Fenwick  ("The  Lancet,"  1877),  Quinke 
("Samml.  klin.  Vortrage,"  No.  100,  1876),  Nothnagel  ("Deutsch. 
Arch.  f.  klin.  Med.,"  Bd.  xxiv,  1879),  Osier  ("Amer.  Jour.  Med. 
Sciences,"  April,  1897),  Kinnikut  ("Amer.  Jour.  Med.  Sciences," 
October,  1887),  also  Rosenheim  and  G.  Meyer  (both  in  article  on 
"Achylia,"  by  Martins  and  Lubarsch),  have  described  cases  of  per- 
nicious anemia  in  which  atrophy  of  the  gastric  mucosa  was,  at  the 
autopsy,  found  to  be  the  only  organic  disease  existing.  It  is  con- 
ceivable that  the  intestine  can  not  persistently  digest  an  amount  of 
proteid  sufficient  to  maintain  the  nitrogen  equilibrium  during  work ; 
that  it  depends  upon  a  certain  part  of  this  proteolysis  to  be  performed 
by  the  stomach;  that  the  acid  gastric  chyme  is  necessary  for  the 
stimulation  of  the  duodenal  secretions.  It  is  probable  that  digestion 
in  the  duodenum  is  not  perfect  without  the  acid  proteids,  which,  as  we 
know,  cause  increased  diastatic  action  of  the  pancreatic  juice  (B.  K. 
Rachford,  "Am.  Journ.  Physiol.,"  vol.  11,  p.  494,  July,  1899). 

So  I  take  the  ground  that  the  supplementing  of  HCl  is  rational, 
even  if  we  can  not  supply  the  deficit,  because  the  amount  necessar}'' 
thereto  could  not  expediently  be  administered.  If  we  can  not  always 
add  sufficient  HCl  to  make  the  chyme  distinctly  acid,  we  can  at  least 
add  enough  to  disinfect  it  and  free  it  from  a  part,  the  surplus,  of  its 
germs,  and  perhaps  produce  some  of  the  preliminary  stages  to  pep- 
tone ;  for  the  acid  albumins  (syntonin)  and  propeptones  are  absorb- 
able, and  those  not  absorbed,  we  believe,  are  of  some  further  utility 


332  IMPORTANT   MKDICINAlv   AGENTS    IN   GASTRIC   THERAPY. 

in  duodenal  digestion.  This  conclusion  is  based  upon  quantitative 
analyses  of  human  duodenal  contents,  from  cases  of  achylia  gastrica 
and  from  normal  individuals.  In  some  cases,  however,  we  are  en- 
abled to  add  enough  to  give  the  reaction  of  free  HCl  to  the  chyme. 

According  to  Honigmann  and  von  Noorden  ("Zeitschr.  f.  klin. 
Medizin,"  Bd.  xiii),  one  part  by  weight  of  pure  HCl  is  able  to  satu- 
rate 1 8  parts  by  weight  of  egg-albumen;  loo  drops  of  dilute  hydro- 
chloric acid,  containing  12.5  per  cent,  of  the  absolute  HCl,  will 
suffice  to  digest  15  gm.,  or  225  gr. — little  less  than  4  drams  of  pure 
egg-albumen.  Riegel  cites  this  statement  {loc.  cit.,  p.  258),  evi- 
dently to  show  how  inefficacious  100  drops  of  a  12.5  per  cent,  solution 
of  HCl  are  as  a  digestive.  (The  dilute  hydrochloric  acid  of  the  U.  S. 
Pharmacopeia  is  a  ten  per  cent,  solution.) 

The  conclusions  of  Honigmann  and  von  Noorden,  however,  are, 
in  our  opinion,  not  calculated  to  inspire  therapeutic  skepticism.  An 
amount  of  proteids  equal  to  4  drams  of  dried  egg-albumen  is  a  con- 
siderable quantity  to  be  relieved  of,  and  it  can  not  fail  to  ease  gastric 
digestion  to  give  the  acid,  even  if  it  can  do  no  more  work  than  this. 
But  then  it  is  practicable  to  give  more  than  100  drops  of  dilute  HCl 
if  necessary.  Furthermore,  the  albumen  molecule  need  not  be 
saturated  in  order  to  become  absorbable,  as  we  shall  see.  Not  near  so 
much  HCl  is  required  for  the  formation  of  acid  albumen  as  for  that 
of  hemialbumose  or  peptone. 

Riegel  himself  succeeded  in  causing  a  resumption  of  secretion  of 
HCl  in  a  patient  who  had  not  shown  any  for  months,  after  he  had 
taken  1.5  gm.  of  hydrochloric  acid  daily  for  fourteen  days.  He 
believes,  however,  that  diet  and  lavage  may  have  had  much  to  do 
with  the  recovery. 

Reichmann  and  Mintz  ("Wiener  klin.  Wochenschr.,"  1892)  report 
several  cases  in  which  free  HCl  could  be  again  demonstrated  after 
it  had  been  missing  for  a  long  time ;  the  resumption  of  HCl  secretion 
was  attributed  by  them  to  a  prolonged  dosage  with  the  same  acid. 
As  we  shall  see  in  the  chapter  on  Achylia,  this  disease  may  depend 
on  a  number  of  very  different  factors.  Sometimes  there  is  no  evi- 
dence of  pathological  change  in  the  mucosa,  and  naturally  these  may 
readily  recover  (neuroses),  even  without  HCl  treatment. 

Professor  Biedert  claims  to  have  used  120  drops  of  dilute  HCl 
daily  for  a  number  of  years,  with  much  benefit  to  his  achylia  (Biedert 
and  Langermann,  "Diatetik  u.  Kochbuch  f.  Magenkranke,"  1895). 
Hanni  introduced  into  the  stomach  400  c.c.  of  a  2.5:  1000  solution  of 


THERAPEUTIC   DOSES   OE   HYDROCHLORIC   ACID.  333 

HCl,  containing  also  2  gm.  of  pepsin,  together  with  an  Ewald  test- 
breakfast.  As  early  as  fifteen  minutes  afterward,  when  some  of  the 
test-meal  was  withdrawn,  the  free  HCl  had  completely  disappeared 
and  the  digestive  power  of  the  sample  was  equal  to  zero  (Hanni, 
"Zeitschr.  f.  klin.  Med.,"  Bd.  xix,  Supplement,  p.  307);  and  Boas 
cites  this  statement  to  show  that  the  digestive  value  of  HCl  therapy 
is  doubtful.  Now,  a  patient  who  gets  rid  of  400  c.c.  of  liquid  in 
fifteen  minutes  has  hypermotility ;  so  much  could  not  possibly  be 
absorbed  in  that  short  period  (the  stomach  does  not  absorb  dilute 
HCl  solutions).  Nor  could  all  of  i  gm.  of  absolute  HCl  which  400 
c.c.  of  a  2.5:  1000  solution  contain  enter  into  combination  with  the 
proteid  of  a  single  roll ;  for  1 00  gm.  of  wheat  roll  contain  only  7  gm. 
of  nitrogenous  or  HCl-binding  materials.  We  know,  however,  that 
I  gm.  of  absolute  HCl  can  digest  18  gm.  of  dried  egg-albumen.  There- 
fore the  400  c.c.  had  probably  all  been  rapidly  expelled  into  the 
duodenum  before  they  could  even  be  thoroughly  triturated  with 
the  test-breakfast.  This  does  not  occur  normally,  and  we  are  not 
justified  in  drawing  conclusions  from  such  hyperkinetic  cases  regard- 
ing the  value  of  HCl  therapy. 

As  the  amount  of  absolute  HCl  introduced  in  Hanni's  experi- 
ments equaled  i  gm.,  and  as  so  much  could  not  enter  into  combina- 
tion with  the  proteid  of  one  roll,  or  100  gm.  of  wheat  bread,  it  stands 
to  reason  that  if  the  motility  had  not  been  so  exaggerated,  some  of 
the  HCl  would  have  been  regained.  Whenever  Hanni  {loc.  cit.,  p. 
306)  succeeded  in  regaining  some  of  the  solution  of  HCl  after  it  had 
remained  in  the  stomach  forty-five  to  sixty  minutes,  or  even  thirty 
minutes  (see  cases  No.  3,  Schmid,  and  No.  4,  Hanni,  p.  307,  loc.  cit.), 
the  tests  for  HCl  were  positive  and  fibrin  was  well  digested  by  the 
filtrate.  The  experiments  of  von  Mehring,  Moritz,  and  myself  ap- 
parently agree  in  permitting  the  deduction  that  fifteen  minutes  is  an 
abnormally  rapid  time  for  the  expulsion  of  400  c.c.  of  liquid  (even 
if  it  were  only  water)  into  the  duodenum,  and  whenever  there  is  a 
fuller  meal  given  than  a  simple  test-breakfast,  this  rapid  expulsion 
does  not  occur,  because  solid  and  semisolid  matter  can  not  be  moved 
out  so  readily.  Again,  we  must  make  allowance  for  a  certain  un- 
avoidable nervous  tension,  and  for  the  influence  of  suggestion,  which 
takes  hold  of  patients  under  experimentation,  and  which,  from  ex- 
perience, we  know  has  a  decided  influence  on  the  rate  of  peristalsis. 

A  careful  series  of  analyses,  constituting  a  rational  basis  for  HCl 
therapy,  is  that  of  Charles  E.  vSimon  ("The  Modern  Aspect  of  In- 


334         IMPORTANT   MEDICINAL   AGENTS    IN   GASTRIC   THERAPY. 

dicanuria,"  "Amer.  Jour.  Med.  Sciences,"  Aug.,  1895,  p.  170).  We 
submit  a  number  of  his  conclusions : 

"(i)  The  gastric  juice  possesses  antiseptic  and  germicidal  prop- 
erties. 

' '  (2)  These  properties  are  referable  to  the  presence  of  free  hydro- 
chloric acid. 

"  (3)  A  subnormal  amount  of  free  hydrochloric  acid  will  call  forth 
an  increased  degree  of  intestinal  putrefaction. 

' '  (4)  The  conjugate  sulphates  form  an  index  of  the  degree  of 
intestinal  putrefaction. 

"(5)  The  increased  intestinal  putrefaction  in  cases  of  subacidity 
and  anacidity  of  the  gastric  juice  is  largely  referable  to  an  increased 
formation  of  indol. 

' '  (6)  The  elimination  of  indican  in  the  urine  may  be  regarded  as 
an  index  to  the  amount  of  free  hydrochloric  acid  present. 

"  (7)  A  normal  acidity  of  the  gastric  juice  is  never  associated  with 
increased  indicanuria. 

' '  (8)  Cases  of  ulcer  of  the  stomach  apparently  form  an  exception 
to  this  rule,  an  increased  indicanuria  being  usually  associated  with 
hyper  chlorhy  dria . 

"(9)  In  other  cases  of  hyperchlorhydria  a  subnormal  or  normal 
amount  of  indican  is  eliminated." 

We  therefore  recommend  hydrochloric  acid,  believing  in  its  efiScacy 
in  supplementing  the  digestive  work  of  the  stomach.  Whenever  it 
is  indicated,  we  usually  give  20  drops  of  the  diluted  HCl  (U.  S. 
Pharm.)  in  2  ounces  of  water  every  half  hour,  beginning  fifteen 
minutes  before  the  meal;  then  20  drops  are  taken  during  the  eating, 
and  20  drops  one-half  hour  after  the  meal.  The  medicine  should 
always  be  taken  through  a  glass  tube,  and  the  mouth  rinsed  with 
a  weak  solution  of  sodium  carbonate  afterward.  As  a  remedy  for 
improving  the  appetite,  HCl  is  conceded,  even  by  those  skeptical  of 
its  digestive  power,  to  be  of  value.  For  this  purpose  it  is  best  given 
in  small  doses  diluted  with  water  (10  to  20  drops  in  3  ounces  HjO), 
on  an  empty  stomach,  before  meals.  With  regard  to  its  disinfectant 
and  antifermentative  effect  I  entertain  serious  doubts,  since  it  can 
not  be  given  in  sufficient  quantity  to  be  of  much  benefit  in  that  direc- 
tion when  given  with  meals.  Whenever  there  are  decided  fermenta- 
tions in  the  stomach,  lavage  is  the  most  efficient  means  of  combating 
it,  and  for  this  purpose  HCl  in  the  form  of  a  6  :  1000  solution  ma}'^  be 
used. 


EFFECT   OF   ALEL^UES   ON   GASTRIC   SECRETION.  335 

Hydrochloric  acid  is  contraindicated  when  the  normal  gastric 
secretion  is  augmented.  We  have  observed  cases  in  which  there 
was  no  free  HCl  to  be  detected  by  Congo  paper  or  phloroglucin- 
vanillin,  but  HCl  given  per  os  produced  gastric  distress  and  pain; 
so  that  there  can  be  no  doubt  that  cases  of  hyperesthesia  toward 
HCl  exist  analogous  to  those  described  by  Talma  ("Zeitschr.  f. 
klin.  Med.,"  Bd.  viii),  which  do  not  depend  upon  hyperchylia.  One 
female  patient  could  detect  whenever  8  drops  of  the  diluted  acid 
were  given  surreptitiously  in  the  meals  or  medicine,  by  the  gastralgia 
caused  thereby.     This  was  a  highly  neuropathic  case. 

The  amount  of  HCl  consumed  in  the  digestion  of  albumin  has 
been  very  carefully  studied  by  Fleischer.  It  takes  0.05  gm.  of  HCl 
to  transform  i  gm.  of  egg-albumen  into  acid  albumin.  As  human 
beings  frequently  take  in  150  gm.  of  egg-albumen  in  twenty -four 
hours,  it  would  require  7.5  gm.  of  pure  HCl  (or  30  gm.  of  the  25  per 
cent,  solution  of  the  laboratories)  to  transform  this  amount  into  acid 
albumin.  As  the  gastric  juice  contains  HCl  to  the  amount  of  2  per 
mille,  2)i  liters  of  gastric  juice  would  be  required  to  digest  that 
amount  of  egg-albumen.  Many  children  consume  about  one  liter 
of  milk  daily;  this  would  require  4.5  gm.  of  pure  HCl  or  18  gm.  of  a 
25  per  cent,  solution  of  HCl  (100  gm.  of  cows'  milk  combined  with 
0.45  gm.  of  HCl).  These  amounts  of  HCl  would  bring  the  ingested 
albumen  only  to  the  stage  of  acid  albumin  or  syntonin ;  but  as  hemi- 
albuminose  and  peptone  would  require  twice  the  amount  of  HCl,  the 
quantity  combined  with  must  eventually  be  increased  beyond  the 
figures  stated.  A  portion  of  the  albuminous  foods  passes  over  into 
the  intestine,  however,  and  there  is  digested  long  before  it  reaches 
the  stage  of  hemialbumose ;  but  when  the  transit  of  the  food  into  the 
duodenum  is  obstructed,  it  is  evident  that  enormous  quantities  of 
HCl  must  be  secreted  to  digest  all  the  albumin  that  is  taken  in.  For 
a  purely  physiological  reason,  it  is  not  possible  that  the  glandular 
layer  can  secrete  the  requisite  amount.  The  absence  of  free  HCl 
in  these  cases  may  be  due  to  an  invasion  of  the  mucosa  by  the  disease 
causing  the  pyloric  obstruction.  It  is  not  impossible,  however,  that, 
even  without  this  invasion,  the  mucosa  has  become  exhausted,  its 
secretory  function  being  paralyzed. 

The  Alkalies. — Probably  the  earliest  experiments  upon  the  effect 
of  alkalies  on  the  gastric  secretion  are  those  by  Claude  Bernard,  who 
found  that  in  small  doses  they  increased  the  secretion-  of,  and  in 
large  doses  they  neutralized,  the  gastric  juice  in  animals. 


336         IMPORTANT   MEDICINAL   AGENTS   IN    GASTRIC   THERAPY, 

Leube  (in  von  Ziemssen's  "Handbuch,"  Bd.  vii)  stated,  as  a  result 
of  experiments  on  dogs  with  gastric  fistulae,  that  the  carbonate  of 
soda  of  the  Carlsbad  springs  not  only  neutralized  an  excess  of  acid, 
but  could  cause  a  lasting  increase  in  the  HCl  formation  of  a  diseased 
mucosa. 

Du  Mesnil  ("Deutsch.  med.  Wochenschr.,"  i892),and  Linossier  and 
Lemoine  (Academic  de  Medicin  de  Paris,  session  of  March,  1893),  agree 
in  stating  that  when  sodium  bicarbonate  is  given  together  with  a  test- 
breakfast,  or  shortly  before  it,  it  acts  as  an  excitant  to  the  mucosa 
and  increases  the  percentage  of  HCl  formed.  In  a  case  of  hyper- 
acidity, however,  Du  Mesnil  found  that  the  amount  of  HCl  was  at 
once  reduced.  Indeed,  the  results  of  various  experimenters  differ 
according  to  the  normal  or  abnormal  state  of  the  stomach  with  which 
they  worked.  It  makes  much  difference,  also,  whether  an  alkali  is 
given  on  an  empty  stomach,  with  very  little  or  no  secretion,  when 
it  may  possibly  act  as  an  irritant  to  the  mucosa  and  set  up  a  secre- 
tory reaction,  or  whether  it  is  given  at  the  height  of  digestion  and 
meets  with  free  HCl;  in  the  latter  case  it  must  of  necessity  combine 
with  the  acid,  and  can  cause  no  further  secretion. 

It  is  unfortunate  for  the  evolution  of  truth  in  this  question — 
whether  or  not  small  doses  of  alkali  can  stimulate  secretion — that 
quite  a  number  of  experimenters  (Hwald  and  Sandberg,  Leube, 
Spitzer,  etc.)  worked  with  Carlsbad  salts  or  water  instead  of  with  a 
chemically  pure  simple  salt.  The  people  of  other  countries  do 
not  share  that  intense  interest  in  the  Carlsbad  and  other  springs 
with  the  physicians  of  Europe;  or  at  least  those  of  Germany  and 
Austria. 

There  are  not  a  few  prominent  representatives  among  the  German 
clinicians  who  have  expressed  grave  doubts  whether  the  cures  and 
improvements  reported  are  really  due  to  the  waters  of  Carlsbad,  but 
that  the  credit  must  be  given  to  the  avoidance  of  bad  home  influences, 
the  careful  diet,  the  regular  life,  pure  air,  good  sleep,  and  abstinence 
from  alcohol  (see  pp.  315-318).  Personally,  we  consider  it  our  duty 
to  emphasize  that  the  waters  of  the  Congress  and  Hathorn  Springs, 
of  Saratoga,  N.  Y.,  and  of  the  Bedford  Springs,  in  Pennsylvania, 
have  produced  similar  marked  improvement,  and,  when  this  was  not 
possible,  great  alleviation  of  gastric  symptoms  there  treated.  But 
even  here  it  is  impossible  to  ignore  the  good  which  the  strict  observ- 
ance of  the  factors  of  hygiene  and  diet  above  mentioned  may  have 
worked. 


COMPOSITION    OF    CARLSBAD    SALT.  337 

The  natural  Carlsbad  Sprudel  salt  has  the  following  composition, 
according  to  Prof.  E.  Ludwig: 

Sodium  sulphate,      41.62  per  cent. 

Potassium  sulphate, 3-3^ 

Sodium  bicarbonate, 3°-^^ 

Lithium  carbonate, 0-2 

Sodium  chlorid, iS.ig 

Sodium  borate, 0.03 

Water, 0-44 

The  artificial  Carlsbad  salt,  which,  according  to  Boas,  can  fully 
replace  the  more  expensive  natural  salt,  contains  the  following  salts, 
according  to  the  German  Pharmacopeia : 

Sodium  sulphate  (dried), , 44  parts. 

Potassium  sulphate, 2 

Sodium  chlorid, ^° 

Sodium  bicarbonate, 3" 

In  hyperchylia  and  hypersecretion  (in  gastric  ulcer)  it  is  given  in 
doses  of  one  to  two  dessertspoonfuls  in  i  of  a  liter  of  water,  to 
reduce  the  excess  of  HCl  and  promote  evacuation.  In  gastritis  it 
is  also  recommended,  and  this  has  seemingly  given  the  Carlsbad 
enthusiasts  much  difficulty,  namely,  to  explain  how  the  identical 
solution  may  produce  reduction  of  the  HCl,  and  in  another  case 
promote  HCl  formation. 

We  have  studied  eight  cases  who  went  to  Carlsbad  suffering  from 
subacidity  and  from  achyHa;  we  have  not,  in  a  single  instance, 
observed  a  return  of  secretion  where  it  was  lost  or  an  increase  where 
it  was  deficiently  formed. 

Reichmann  is  one  of  the  few  who  objected  to  applying  the  deduc- 
tions found  with  Carlsbad  water  or  salts,  on  account  of  their  com- 
plexity, to  the  effects  of  pure,  simple  alkaline  salts  ("Therapeut. 
Monatshefte,"  1895).  We  have  never  shared  the  opinions  of  those 
who  believe  that  small  doses  of  alkali  given  on  an  empty  stomach 
can  produce  a  reactive  secretion  of  HCl  which  may  exceed  the  amount 
necessary  to  combine  with  the  alkah  given.  We  can  understand 
that  strong  solutions  of  sodium  and  potassium  sulphate,  such  as  the 
Carlsbad  water,  may  actually  play  the  role  of  an  irritant,  to  which 
the  mucosa  responds  in  the  form  of  an  increased  secretion,  just  as 
the  nasal  mucosa  would  do  if  a  crystal  of  salt  were  placed  in  the 
nasal  passage.  Indeed,  N.  Reichmann  declares,  after  -a  series  of 
careful  analyses  with  Na^COs,  that  the  bicarbonate  of  sodium  does 


338      IMPORTANT  me;dicinal  agents  in  gastric  therapy. 

not  act  up07i  the  secretory  mechanism  of  the  stomach,  hut  only  upon  the 
juice  already  secreted,  by  neutralizing  it  and  rendering  the  gastric  con- 
tents alkaline  (Boas,  "Archiv  f.  Verdauungskrankh.,"  vol.  i,  p.  44). 

The  actual  therapeutic  application  of  alkalies,  therefore,  is  limited 
to  those  dyspepsias  associated  with  increased  HCl  formation,  in 
simple  neurasthenic  hyperchylia,  in  hypersecretion,  and  in  gastric 
ulcer.  They  are  indispensable  for  lavage  when  it  becomes  neces- 
sary to  neutralize  acids  and  dissolve  adherent  mucus.  The  time  to 
give  alkalies  in  hyperacidity  is  from  one-half  to  one  hour  after  meals, 
when  the  HCl  secretion  is  quantitatively  at  its  height.  The  sensa- 
tions of  the  patient  are  a  very  good  guide,  and  the  time  can  be  learned 
by  experience;  the  alkali  should  then  be  given  a  little  previous  to 
the  time  when  the  gastraliga,  eructation,  pyrosis,  and  distention  set 
in.  In  hypersecretion  there  is  a  large  amount  of  HCl  present  almost 
continuously  in  the  empty  stomach,  in  addition  to  hyperacidity  after 
meals,  so  here  we  should  give  alkalies  before  meals  in  order  to  insure 
a  certain  time  for  action  to  the  ptyalin;  for  this  constant  secretion 
a  glass  of  Saratoga  Vichy,  or  simply  sodium  bicarbonate,  5j,  in  ^ 
of  a  pint  of  plain  cold  water,  before  meals,  is  sufficient  to  permit 
amylolysis.  In  ulcer  and  chronic  gastritis  acida,  alkalies  find  appli- 
cation also  (refer  to  treatment  of  these  diseases). 

Determination  of  the  Amounts  of  Alkalies  Required. — Two  groups 
of  these  bodies  are  in  common  use:  (i)  The  alkaline  earths;  (2)  the 
alkaline  carbonates.  Of  the  first  group,  magnesia  usta  or  calcined 
magnesia,  and  the  more  expensive  magnesium  ammonium  phosphate 
are  the  favorites;  and  of  the  second,  the  sodium  carbonate  and  bi- 
carbonate. Those  alkalies  which  are  capable  of  combining  with  the 
largest  amount  of  HCl  are  preferable.  It  is  expedient  to  avoid 
excess  of  sodium  bicarbonate,  because  the  liberation  of  CO2  in  the 
neutralization  may  cause  annoying  distention  of  muscular  walls 
already  infirm. 

Magnesia  usta  has  the  greatest  binding  power  for  HCl,  and  the 
reaction  is  expressed  in  the  following  -equation : 
MgO  +  2HCI  =  MgClj  +  2H.,0. 

Here  0.55  part  of  MgO  correspond  to  one  part  of  HCl. 

The  reaction  with  ammonio-magnesium  phosphate  is  the  following : 

Mg(NH,)PO,  +  3HCI  =  MgCl,  +  NH.Cl  -f  H3PO,. 

Calculation  here  gives  the  result  that  1.25  parts  by  weight  of 
Mg(NH4)P04  correspond  to  one  part  by  weight  of  HCl. 


BITTER   TONICS   AND    STOMACHIC   REMEDIES.  339 

The  reaction  with  sodium  bicarbonate  is  as  follows: 

NaHCOa  +  HCl  =  NaCl  +  Hfi  +  CO^. 

Calculation  of  the  molecular  weights  shows  that  2.3  parts  of  Na- 
HCO3  correspond  to  one  of  HCl. 

According  to  Boas,  the  dose  of  sodium  bicarbonate  necessary  to 
counteract  a  superacidity  exceeding  2.5  :  1000  is  eight  to  ten  gm., 
or  four  to  six  gm.  of  ammonio-magnesium  phosphate,  or  two  to 
three  gm.  of  magnesia  usta.  With  an  acidity  of  3  :  1000  HCl,  the 
NaHCOg  can  be  increased  to  twelve  gm.,  the  ammonio-magnesium 
phosphate  to  7.5  gm.,  and  the  magnesia  usta  to  five  gm.  These 
calculations  are  made  upon  an  amount  of  stomach  contents  equal 
to  400  c.c. ;  but  as  a  part  of  the  alkali  is  expelled  into  the  duodenum, 
another  part  absorbed,  and  as  the  momentary  quantity  of  HCl 
present  can  only  be  reckoned  upon,  the  figures  may  be  too  low. 
With  constipation  and  collection  of  gas  in  the  intestines  the  preference 
is  to  be  given  to  the  magnesia  salts.  Germain  See  ("Semaine  Medi- 
cale,"  1890,  No.  12)  recommends  the  following: 

Ijt .     Sod.  bicarb., 

Creta  prasp. , 

Magn.  carbon., aa  o.  2  gm.  M. 

Take  at  once. 

Boas'  formula  for  continued  excessive  secretion  is  the  following : 

Metric 
System. 

R.     Magnesiee  ustse, 15.0  gr.  231.5 

Bismuth,  carbon., 

Natrii  carbon., aa  5.0  gr.     77.2 

Ext.  belladonnse, 

Ext.  strychn., aa  0.1-0.2  gr.       1.7.   M. 

SiG. — One  teaspoonful  three  times  daily,  half  an  hour  after  meals. 

The  amount  of  HCl  secreted  should  be  watched  and  the  alkali 
discontinued  if  it  becomes  normal. 

The  Bitter  Tonics  and  So-called  Stomachic  Remedies. — 
Experience  has  lent  belief  that  the  bitter  tonics  are  agents  which 
stimulate  the  appetite  and  the  secretory  and  motor  functions  of  the 
stomach.  They  are  represented  by  preparations  of  condurango, 
quassia,  Colombo,  gentian,  angostura,  absinthe,  nux  vomica  and 
strychnin,  creasote,  guaiacol,  orexin,  lupulin,  cetrarin,  erythrocen- 
taurin,  rheum,  resorcin,  quinia,  cinchona.  Under  certain  conditions, 
HCl,  sodium  chlorid,  and  alcohol  act  as  stomachics. 

Some   writers  class   sodium  bicarbonate   among  these  remedies. 


340         IMPORTANT    MEDICINAIv   AGENTS    IN    GASTRIC   THERAPY. 

Upon  the  supposition  that  small  doses  of  this  alkali  may  stimulate 
secretion  of  gastric  juice;  this  therapy  is,  in  our  opinion,  fallacious. 
As  a  general  rule,  these  medicines  are  useful  to  improve  the  appetite, 
and  as  anorexia  is  mostly  found  in  reduced  or  lost  gastric  secretion, 
the  effect  upon  secretion  is  apparently  the  only  one  that  can  be 
attributed  to  them.  What  the  bitter  tonics  really  effect  and  how 
they  act  is  an  unsolved  problem.  There  seems  to  be  an  absence  of 
scientific  exactness  in  many  of  the  experiments,  and  a  general  diffu- 
siveness regarding  the  special  point  of  inquiry  to  be  solved.  Thus, 
Penzoldt  pretends  that  genuine  stomachics  must  be  able  to  improve 
all  of  the  gastric  functions  (Penzoldt,  on  "Salzsaures  Orexin," 
"Therap.  Monatsh.,"  1890,  No.  2).  Loss  of  appetite  may  be  present 
when  the  functional  work  is  reduced,  and  then  bitter  tonics  would 
be  indicated;  but  it  may  just  as  well  be  present  with  normal  or 
morbidly  increased  functions  when  stomachics  would  do  harm.  For 
instance,  we  have  had  many  cases  of  anorexia  with  hyperacidity 
where  the  appetite  returned  after  the  use  of  bromid  of  strontium. 
In  dilatations  with  fermentation  the  best  stomachic  is  lavage.  As 
even,'  disturbed  function  or  disease  requires  elucidation,  so  the 
anorexia  based  thereon  demands  its  own  adapted  treatment.  Bitter 
tonics  and  allied  medications  are,  in  general,  stimulants  to  the 
mucosa,  and  although  they  have  a  large  application,  it  is  not  rational 
to  use  them  empirically.  A  sedative  or  an  antiseptic  may,  under 
certain  conditions,  be  a  better  medicine  than  the  bitter  tonic  for 
anorexia.  The  most  rational  course  to  pursue  is  to  ascertain  the 
exact  state  of  the  gastric  functions,  and  after  the  establishment  of 
the  diagnosis  attempt  to  remove  the  cause  of  the  anorexia,  whether 
it  is  depressed  motility,  accumulation  of  mucus,  fermentation,  or 
impaired  secretion.  For  a  fuller  account  of  the  physiological  effects 
of  these  remedies  the  reader  is  referred  to  recent  works  on  pharma- 
cology and  therapeutics. 

The  most  useful  medicines  of  this  class,  in  my  experience,  have 
been  str}^chnin  and  condurango,  which,  according  to  the  experi- 
ments of  L.  Wolff,  have  no  appreciable  effect  on  the  rate  of  secretion 
("Zeitschr.  f.  klin.  Med.,"  Bd.  xvi,  S.  222).  Reichmann's  very 
carefully  conducted  investigations  ("Zeitschr.  f.  klin.  Med.,"  Bd. 
XIV,  Heft.  I  und  2)  brought  out  the  fact  that  some  bitter  tonics 
failed  to  cause  any  secretion  of  gastric  juice  when  distilled  water 
did;  and  whenever  water  failed  to  produce  secretion,  the  bitter 
remedies  failed  also.     On  normal  digestive  processes  these  agents 


FORMULAS  FOR  TREATMENT  OF  ANOREXIA.         34 1 

have  no  effect ;  but  when  a  juice  was  secreted  that  was  acid,  though 
not  containing  HCl,  and  if  a  gastric  juice  ven^  weak  in  pepsin  was 
secreted,  then  the  bitter  tonics,  especially  absinthe,  were  found  to 
produce  a  stronger  degree  of  acid  and  distinct  reaction  for  HCl. 
^^^henever  there  was  atrophy  of  the  glandular  apparatus,  all  of  these 
remedies  failed  to  cause  a  secretion  of  gastric  juice  containing  HCl. 
In  brief,  his  conclusions  are  that  the  effect  is  very  variable,  some- 
times less  than  that  of  water;  but  sometimes  there  is  an  increase  of 
secretion  after  the  bitter  tonic  has  become  absorbed  and  disappeared. 
They  act  best  when  given  before  meals,  and  when  there  is  a  gastric 
secretion  still  present,  but  much  reduced  (hypochylia).  In  hyper- 
secretion Reichmann  found  that  the  acidity  was  still  further  in- 
creased b}'  bitter  tonics.  We  advise  that  the  bitter  tonics  should 
be  given  only  in  hypochylia  or  subacidity,  and  then  one-half  hour 
before  meals.  The  author's  favorite  formula  for  anorexia  from 
hypochylia  is  the  following: 

*  Metric  System. 

U.      Strychnin,  sulphas,    ........       0.020  gr.  i/^ 

Acid,  hydrochloric,  dil., 14.787  f^ss 

Ext.  condurango  fl., 45.361  ^^iss 

Elixir  gentian., q.  s.  ad  177.442  f^^j-               M- 

SiG. — One-half  of  a  fluidounce  in  two  ounces    of  water,  one-half  hour  before 
meals,  through  a  glass  tube. 

Or— 

Metric  System. 

R.     Tinct.  nucis  vomic, lo.o  f^iiss 

Essentiae  calisayae  (P.  D.  &  Co.),      .     60.0  f^ij 

Elixir  gentian., q.  s.  180.0  ^o^j-  ^^* 

SiG. — One-half  of  a  fluidounce  thrice  daily,  one-half  hour  before  meals. 

When  there  are  evidences  of  anemia  with  the  hypochylia,  the 
following  acts  satisfactorily: 

Metric  System. 

H  •     Quininae  sulphatis, I-I93  gr-  xviij 

Strychnin,  sulphatis, 0.020  gr.  ]/^ 

Ferri  sulphatis, 0.775  g*"-  ^^'j 

Acid,  arseniosi, o.oi2-|-  gr.  \.             M. 

SiG. — Fiat  pil.  No.  xij.     One  pill  three  times  daily  (must  be  prepared  fresh  and 
not  coated). 

Boas  uses  the  following  powder  for  anorexia : 

Metric  System. 

R.     Ext.  strychn., 0.03-0.05  gr.  f 

Bismuth,  carbon., 0.50  gr.  viij. 

M.  f.  pulv.     Dent.  tal.  dos.  xx. 
SiG. — One  powder  three  times  daily. 


342  IMPORTANT   MEDICINAI^   AGENTS    IN    GASTRIC   THERAPY. 

Menche  has  warmly  recommended  resorcin  sublimate,  and  it  un- 
deniably improves  the  appetite  in  cases  of  incipient  gastric  fermenta- 
tion. It  has  also  a  slight  sedative  action.  The  following  is  Menche's 
formula : 

Metric  System, 

IJ.     Resorcin.  resublim., 2.0  gr.  30.5 

Acid.  mur. , i.o  gr.  15.4 

(Or,  if  it  be  indicated  in  place  of  the  HCl,  one  may  order  Natr. 
bicarb.,  8.0.) 

Aquae  destil., 180.0  ^5^] 

Syr.  simpl., 20.0  ^iij- 

M.  D.  et  ad  vitr.  nigr. 
SiG. — Fifteen  c.c.  (  ^ss)  every  two  hours. 

The  following  formulae  are  recommended  by  Kwald  for  anorexia 
with  fermentation. 

Metric  System. 

R.     Tinct.  nucis  vom., 25.0  f^vj 

Resorcin.  resublim., 5.0  gr.  Ixxxj     ■ 

Tinct.  amar. , lo.o  f^^'j-  M- 

Take  ten  to  fifteen  drops  every  two  hours. 

U.     Ext.  condurang.  fl., 16.0  f^ivss 

Resorcin.  resublim., 4.0  gj.  M. 

SiG. — Thirty  drops  four  times  daily. 

Creosote  is  a  remedy  of  doubtful  efficacy  in  my  experience,  as 
it  rarely  benefits  digestion  except  in  tuberculous  patients.  Wegele 
says  {loc.  cit.,  p.  53)  that  it  will  help  if  it  is  tolerated  and  causes  no 
severe  dyspeptic  difficulties,  but  the  latter  is  just  what  it  will  do  in 
more  than  one-half  of  the  cases.  I  have  my  doubts  whether  it  can 
promote  peristalsis,  as  is  asserted  by  Klemperer  ("Centralbl.  f. 
klin.  Med.,"  1891,  No.  21),  until  enough  is  given  to  act  as  an  irritant. 
Even  when  it  is  tolerated  by  the  stomach,  the  repeated  penetrating 
eructations  are  very  annoying  to  patients.  Sommerbrodt  recom- 
mended it  to  be  taken  in  capsules.  Bouchard  advises  the  following 
formula : 

Metric  System. 
li .     Creosot.  puriss., 13.5 

Tinct.  gent., 20.0 

Yin.  Xerens, 800.0 

Spir.  rectif., 200.0  M. 

SiG. — One-half  of  an  ounce  four  times  daily. 

Orexin  (phenyldihydrochinazolin)  has  been  strongly  indorsed  as 
a  "genuine"  stomachic  by  Penzoldt.  In  273  cases  he  observed  144 
successful  restorations  of  appetite  and  secretion.  Its  special  indi- 
cations are  gastric  atony  and  beginning  gastritis,  and  its  action  is 


ARTIFICIAL    DIGESTIVE    FERMENTS.  343 

attributed  to  its  power  of  increasing  the  secretion  of  HCl  (Penzoldt, 
"Weitere  Mittheilungen  iiber  Orexin  basicum,"  etc.,  "Therap. 
Monatshef te, "  May,  1893).  The  following  formula  is  advised  by 
Penzoldt  for  this  useful  drug: 

U  .      Orexin  basic, ^  ss,  or  2  gm. 

SiG. — Divide  into  six  powders;   inclose  in  small  wafers.      One  to  be  taken  in  a 
cup  of  bouillon  half  an  hour  before  meals,  twice  daily. 

Digestive  Ferments. — Artificial  means  of  aiding  digestion  are 
certainly  much  abused,  and  if  employed  for  long  periods,  they  fre- 
quently become,  to  a  certain  extent,  injurious.  Every  organ  is 
strengthened  by  activity  and  weakened  by  lack  of  exercise.  The 
stomach  will  grow  weaker  and  weaker  the  more  artificial  gastric  juice 
is  poured  into  it,  and  the  finer  and  more  subtle  the  nourishments 
are  that  are  allotted  to  it.  This  agrees  in  the  main  with  what  we 
stated  under  Dietetics,  namely,  that  the  diet  should  not  be  leveled 
down  to  the  digestive  capabilities  of  the  stomach,  but  that  digestion 
should  be  leveled  up  until  it  can  deal  efficiently  with  the  amount  of 
food  required  for  the  nitrogen  equilibrium.  In  truth,  the  indis- 
criminate dosing  with  digestive  ferments  does  more  harm  than 
good.  The  stomach  is  an  organ  which  very  rapidly  adapts  itself 
to  cease  performing  the  work  that  is  done  for  it  artificially.  Then, 
again,  there  is  such  a  thing  as  educating  an  apparently  weak  stomach 
up  to  digesting  food  which  at  first  seems  indigestible,  and  is  taken 
with  "fear  and  trembling."  So  we  will  find  that  gastric  training 
(gymnastics  of  digestion)  by  graded  diet  may  favor  the  develop- 
ment of  what  fragments  of  glandular  elements  may  yet  be  slumber- 
ing in  a  diseased  mucosa,  but  the  irrational  use  of  ferments  may,  by 
doing  all  the  work  itself,  permit  the  gland-cells  to  go  on  to  atrophy. 

The  artificial  ferments  have  been  recommended  when  there  is  a 
deficiency  or  absence  of  the  natural  secretion.  They  may  be  con- 
sidered in  two  classes:  (i)  Those  that  have  been  isolated  from  the 
mammalian  organism — viz.,  ptyalin,  pepsin,  pancreatin;  and  (2) 
those  derived  from  the  vegetable  kingdom — viz.,  the  various  dias- 
tases, papain,  bromilin.  Some  of  the  ferments  of  the  human  body 
have  not  yet  been  isolated;  these  are  the  milk-curdling  ferments  of 
the  gastric  and  pancreatic  juices  and  the  emulsifying  and  fat- 
splitting  ferments.  There  are  ferments  in  the  succus  entericus 
(invertin,  etc.,  perhaps  a  curdling  ferment)  which  we  understand 
very  little. 

Ptyalin. — This  ferment  of  the  saliva  is  indicated  in  hyperacidity 
23 


344         IMPORTANT   MEDICINAL   AGENTS   IN   GASTRIC   THERAPY. 

and  hypersecretion,  when  the  normal  pt^^alin  may  actually  be  de- 
stroyed in  the  stomach.  Boas  has  shown  that  with  diminution  of 
the  acidity  this  ferment  may,  to  a  degree  at  least,  resume  its  inversion 
of  starches  into  dextrose.  With  very  intense  hyperacidity  (0.04: 
1000)  the  ferment  appears  to  be  so  injured  that  it  can  not  be  re- 
stored to  function,  and  a  new  supply  may  be  necessar}^  Pt^^alin 
is  given  in  doses  of  five  to  fifteen  grs.,  with  3j  of  sodium  bicarbonate, 
immediately  after  meals.  There  can  be  no  doubt  of  the  greater 
amount  of  dextrose  formed  with  the  aid  of  pt3'alin,  and  these  patients 
are  thereby  enabled  to  eat  more  of  carbohydrates. 

Diastase. — Malt  diastase,  as  manufactured  in  the  form  of  liquid 
extract,  or  in  dry  form,  as  in  Horlick's  diastoid,  is  serviceable  for 
the  same  purpose.  Professor  Leo,  of  Bonn  ("Therap.  Monatshef te, " 
Dec,  1896),  reported  to  the  Congress  of  German  Naturalists  and 
Physicians  on  taka-diastase,  an  American  product,  which  appears 
to  have  strong  starch-inverting  power,  and  to  be  able  to  act  in  an 
amount  of  acid  equal  to  o.i  per  cent.  HCl.  \\^e  have  assured  our- 
selves that  amylolysis  is  effectually  carried  out  by  this  taka-diastase, 
but  the  addition  of  an  alkali  is  necessary,  as  with  ptyalin,  to  render 
the  effect  prompt.  Its  tastelessness  and  moderate  price  are  in  its 
favor. 

Ewald  has  found,  in  a  great  many  observations,  that  absence  or 
deficiency  of  ptyalin  is  exceedingly  rare;  so  that  ptyalin  is  rarely 
required  because  it  is  secreted  in  sufficient  quantity,  but  in  some 
way  it  may  be  destroyed.  The  hygiene  of  the  mouth  should  receive 
careful  attention;  a  septic  or  acid  mouth,  with  coated  tongue  and 
bad  teeth,  will  offset  any  amount  of  ptylin.  To  treat  "amylaceous 
dyspepsia" — which  is  the  objectionable  name  given  to  symptoms  of 
hyperacidity  and  hypersecretion — by  cutting  off  the  carbohydrates 
is  irrational,  because  they  can  not  be  dispensed  with,  not  on  account 
of  the  starch  only,  but  on  account  of  the  proteid  which  amylaceous 
foods  contain.  It  will  be  found,  from  the  army  rations  of  men  under 
service  of  various  nations,  that  the  carbohydrate  portion  of  the 
foods  is  increased  with  harder  work  much  more  than  the  proteid 
aiid  fat  portion  (see  tables  in  Gilman  Thompson's  "Dietetics"  and 
Munk  and  Uffelmann's  "Ernahrung  des  Menschen").  Therefore 
these  foods  should  not  be  taken  away  because  they  may  not  be  per- 
fectly digested ;  but  the  cause  of  the  indigestion  should  be,  if  possible, 
removed.  If  possible,  a  large  amount  of  natural  saliva  should  be 
swallowed  after  meals;  manv  times  have  we  obser\^ed  that,   with 


PEPSIN    AND   PANCREATIN.  345 

the  simple  supply  of  additional  saliva  caused  by  chewing  a  piece 
of  rubber,  starch  indigestion  could  not  be  demonstrated  in  the  test- 
meal,  although  it  had  existed  before.  To  Fothergill  is  attributed 
the  saying  that  ferments  are  crutches ;  no  doubt  many  an  invalid 
would  prefer  walking  on  crutches  than  not  at  all.  There  are  many 
crutch-walkers,  however,  who,  by  modem  surgery,  have  been  enabled 
to  throw  them  away  and  walk  by  themselves  unaided.  Just  so  with 
the  ferments;  the}^  ma}^  be  used  with  success  temporarily,  but  the 
best  thing  to  do  is  to  discover  how  the  patient  may  digest  without 
them. 

Pepsin. — There  is  no  lack  of  pepsin  preparations  in  the  market, 
and  their  digestive  powers,  as  claimed,  seemingly  have  no  limit. 
Certain  vers'  popular  compositions  of  pepsin  should  be  emphatically 
condemned.  For  instance,  all  wines  of  pepsin  are  inefficient  be- 
cause very  little  of  this  ferment  is  taken  up  by  alcohol.  Recently 
a  preparation  w^as  brought  to  our  laboratorv^  containing  hydrastis, 
rhubarb,  pepsin,  and  pancreatin  in  one  solution,  showing  a  total 
disregard  for  the  physiological  fact  that  pepsin  acts  only  in  an  acid 
and  pancreatin  in  an  alkaline  medium.  There  is  rarely  any  indi- 
cation for  the  use  of  pepsin,  for,  whenever  a  test-meal  shows  free 
HCl,  pepsin  must  of  necessity  be  present  in  sufficient  amounts;  and 
even  when  HCl  is  absent,  pepsin  or  pepsinogen  are,  as  a  rule,  still 
present.  Assuming  a  case  in  which  the  last  vestige  of  even  pepsino- 
gen secretion  has  been  lost,  the  introduction  of  the  ferment  might  be 
of  utility,  but  the  enormous  quantities  of  HCl  necessary  to  bring 
about  proper  action  of  this  pepsin  could  not  be  tolerated  by  any 
diseased  stomach  (see  chapter  on  the  Therapy  of  HCl).  And,  again, 
in  cases  where  pepsinogen  is  still  formed,  the  addition  of  HCl  simply 
will  suffice  to  convert  it  into  the  complete  ferment.  Pepsin  is  pre- 
scribed much  too  often;  personally,  I  have  ceased  using  it. 

Pancreatin. — Although  there  are  many  preparations  of  this  fer- 
ment, and  some  of  them  very  active,  the  substance  spoils  and  loses 
its  digestive  power  with  age.  As  it  is  an  easy  matter  to  test  its 
amylolytic  and  tryptic  power  in  artificial  digestion  experiments,  it 
is  wise  to  do  so  in  all  cases  where  much  dependence  is  placed  in  its 
action.  The  nature  and  value  of  the  substance  were  scientifically 
explained  by  Sir  WilHam  Roberts  ("Digestion  and  Diet,"  p.  66). 
It  can  be  obtained  in  a  liquid  form  as  well  as  in  the  form  of  a  dry 
powder,  from  extraction  of  the  pancreatic  gland  of  animals.  This 
ferment  is  completely  destroyed  in  the  gastric  juice.     This  is  why 


346         IMPORTANT    MEDICINAIy   AGENTS    IN    GASTRIC   THERAPY. 

thinking  practitioners  should  not  use  both  pepsin  and  pancreatin 
together  in  the  same  solution,  because  the  medium  in  which  one 
must  act  is  opposed  to  that  of  the  other.  In  the  majority  of  cases 
where  pancreatin  is  given  empirically,  HCl  is  still  secreted  in  the 
stomach  and  the  ferment  is  destroyed.  Oilman  Thompson  {loc. 
cit.,  p.  333)  suggests  that  the  pancreatin  be  inclosed  in  keratin  cap- 
sules. Keratin  is  unaffected  by  gastric  juice,  but  readily  dissolves, 
it  is  claimed,  in  alkaline  media.  Hence  the  pancreatin  may  pass 
through  gastric  digestion,  and  at  its  completion  pass  into  the  in- 
testine, where  the  coating  is  supposedly  dissolved  and  the  ferment 
acts  upon  the  chyle.  The  suggestion  of  Thompson  was  previously 
carried  out  by  Unna.  But  this  idea  is  not  supported  by  experiment 
nor  by  exact  indications  of  the  conditions  for  the  employment  of 
pancreatin.  Keratin  will  not  dissolve  in  the  duodenum  except  very 
slowly;  pills  coated  therewith  are  found  in  the  stools  during  normal 
digestion.  There  is  no  necessity  for  attempting  to  supply  the  fer- 
ment directly  to  the  duodenum,  since  in  the  greater  majority  of  cases, 
perhaps  all,  except  when  malignant  neoplasm,  cirrhosis,  or  abscess 
has  destroyed  the  gland,  there  is  plenty  of  pancreatic  juice  in  that 
part  of  the  bowel.  In  exceedingly  rare  cases  pancreatic  calculi  and 
diseased  states  of  adjacent  parts  may  stenose  the  duct.  In  all  these 
attempts  it  is  overlooked  that  the  reaction  of  the  normal  duodenum 
is  acid  and  will  not  permit  the  solution  of  keratin. 

There  is  but  one  distinct  indication  for  the  use  of  pancreatin, 
and  that  is  permanent  deficiency  or  complete  absence  of  HCl  and 
enzyme  formation  of  the  stomach.  Experiment  and  experience 
have  conclusively  shown  that  when  pancreatic  digestion  is  started 
in  the  stomach  in  these  cases,  by  giving  the  pancreatin  with  sodium 
bicarbonate,  there  is  a  more  exhaustive  utilization  of  the  proteids 
and  carbohydrates.  We  have  frequently  assured  ourselves  of  this 
fact  by  analyzing  the  stools  after  weighed  amounts  of  these  food- 
substances  had  been  ingested,  at  the  same  time  making  identical 
analyses  with  the  same  amounts  of  proteid  and  carbohydrate,  but 
with  pepsin  hydrochloric  acid  as  an  artificial  digestant;  under  the 
latter  more  food-substances  passed  through  undigested  than  when 
pancreatin  was  used. 

Pepsin  and  hydrochloric  acid  naturally  suggest  themselves  in 
atrophic  gastritis,  but  judging  from  our  observations,  pancreatin  is 
preferable.  I  have  noticed  cases  in  which  there  was  a  remarkable 
hypersensitiveness  to  hydrochloric  acid  even  in  doses  of  six  drops 


PAPAIN,  PAPOID,  AND  PAPAYOTIN.  347 

of  the  dilute  form,  so  that  its  use  had  to  be  dispensed  with.  The 
dose  of  pancreatin  is  from  four  to  eight  grains,  together  with  the 
same  amount  of  sodium  bicarbonate  in  form  of  compressed  tablets; 
of  these,  two  to  four  are  taken  fifteen  minutes  after  meals. 

Papain,  Papoid,  Papayotin. — These  ferment-containing  substances 
are  made  from  the  milky  juice  of  a  tree  belonging  to  the  family  of 
Papayacege,  native  in  Central  and  South  America. 

Bouchut  and  Wurtz  ("Sur  la  ferment  digestiv  du  Carica  Papaya," 
"Compt.  Rend.,"  1879,  tomeLxxxix)  first  prepared  papain,  and  later 
Peckolt  brought  out  papayotin.  Papoid,  an  American  preparation, 
according  to  Prof.  R.  H.  Chittenden,  is  a  vegetable  ferment  made 
up  of  vegetable  globulin,  albumoses,  and  peptone,  with  which  are 
associated  the  ferments  characteristic  of  the  preparation.  Papoid  has 
the  power  of  digesting  to  a  greater  or  less  extent  all  forms  of  proteid 
or  albuminous  matter,  both  coagulated  and  uncoagulated ;  its  diges- 
tive power  is  exercised  in  a  neutral,  acid,  as  well  as  alkaline  medium. 
Papoid  is  found  in  the  stools,  showing  that  it  is  not  destroyed  in  the 
alimentary  canal;  the  dose  is  from  one  to  three  grains  after  each  meal. 

Finkler  prefers  papain  to  pepsin  for  aiding  gastric  digestion 
("Therap.  Gazette,"  1887,  August  15th),  and  G.  Littmann  has  ob- 
served good  results  with  it  in  acute  and  chronic  gastritis,  dilatations, 
carcinoma,  and  dyspepsia  after  chronic  ulcer  (Littmann,  "Miinch. 
med.  Wochenschr.,"  No.  29). 

Papain  seems  to  be  a  variable  product  and  its  digestive  action 
not  always  the  same  (Rossbach  and  A.  Eulenberg).  It  is  an  ex- 
pensive preparation.  Recently  a  highly  concentrated  extract  of 
carica  papaya  has  been  brought  into  the  market  under  the  name  of 
caroid,  which,  according  to  Chittenden,  has  even  a  greater  digestive 
power  than  papoid,  and  digests  proteids,  albumins,  and  starches  in  any 
medium.  We  append  Chittenden's  results  with  this  energetic  fer- 
ment, concerning  the  clinical  application  of  which  further  observa- 
tions are  necessary  : 

With  0.05  per  cent,  hydrochloric  acid: 

Undigested  residue.  Proteid  digested. 

Caroid, 0.8024  gm.  20. 2  per  cent. 

Papain,  A, 0.8959     "  10.9         " 

Papain,  B, 0.8735     "  '3-1         " 

With  0.5  per  cent,  sodium  bicarbonate: 

Undigested  residue.  Proteid  digested. 

Caroid, 0.4596  gm.  54.3  per  cent. 

Papain,  A, .    .  O.5691     "  43.4         " 

Papain,  B, 0.5927     "  41.0         " 


348         IMPORTANT  MEDICINAL  AGENTS   IN   GASTRIC  THERAPY. 

If  we  examine  these  results  critically,  it  is  plain  that  the  digestive 
power  of  caroid  on  proteid  matter  is  greater  than  that  of  the  other 
two  preparations.  The  difference  in  digestive  strength  is  more 
apparent  in  these  experiments  with  coagulated  egg-albumen  than 
with  the  other  form  of  proteid  matter,  although  quite  marked  with 
blood-fibrin. 

2.  Starch-digesting  Power. — In  starch-digesting  power  caroid  is 
far  superior  to  the  other  preparations,  either  papoid  or  papain. 
The  following  experiments  will  throw  some  light  upon  this  point. 

A  starch  paste  was  made  from  5  gm.  of  dry  arrow-root  starch  with 
500  c.c.  of  water.     Mixtures  were  then  prepared  as  follows: 

1.  0.5  gm.  of  caroid,         +  90  c.c.  water  -j-  10  c.c.  of  starch  paste. 

2.  0.5      "  "  papoid,        -f        "  "      +  "  "       "           " 

3.  0.5      "  "  papain,  A,  +        "  "      +  "  "       "           " 

4.  0.5     "  "  papain,  B,  +       "  "      -f-  "  "       "          " 

These  four  mixtures  were  placed  at  40°  C,  and  tested  from  time 
to  time  with  iodin  solution.  In  five  minutes  No.  i  had  reached  the 
achromic  point,  while  No.  2  did  not  give  the  achromic  reaction  until 
at  the  end  of  two  hours.  At  the  end  of  three  hours  Nos.  3  and  4 
still  gave  a  bluish-violet  reaction  with  iodin. 

In  another  series  of  experiments  exactly  similar  to  the  above, 
except  that  each  mixture  contained  only  0.2  gm.  of  ferment,  the 
caroid  brought  about  a  complete  conversion  of  the  starch  into  bodies 
non-colorable  by  iodin  in  eighteen  minutes,  while  the  others  gave  a 
blue  reaction  after  two  or  three  hours. 

The  presence  of  alkalies  retards  the  diastatic  or  amylolytic  action, 
but  the  caroid  shows  throughout  very  much  greater  amylolytic 
power  than  the  other  preparations. 

The  Ferments  of  the  Pineapple. — This  fruit  contains  very  active 
proteolytic  ferments,  its  juice  being  used  in  the  production  of  the 
artificial  predigested  beef  foods  by  a  prominent  American  firm. 
The  ferments  are  destroyed  by  boiling,  and  hence  are  no  longer 
active  in  the  preserved  fruit.  We  have  assured  ourselves  suffi- 
ciently of  the  proteolytic  activity  of  raw,  fresh  pineapple- juice  to 
recommend  it  in  achylia  or  subacidity,  and  to  forbid  its  use  in  hyper- 
acidity and  hypersecretion,  as  well  as  in  gastritis  acida.  It  is  allowed 
mainly  because  of  its  pleasant  taste  and  because  it  stimulates  desire 
for  other  food.  The  fiber  must  be  removed  from  the  mouth  after 
chewing,  and  only  the  juice  swallowed. 


HISTORY   OF    GASTRIC    SURGERY,  349 

CHAPTER  VII. 
SURGICAL  TREATMENT  OF  ORGANIC  GASTRIC  DISEASES. 

In  the  preantiseptic  time  the  stomach  was  regarded  as  a  "NoU 
me  tangere."  Even  in  the  beginning  of  last  century  gastric  wounds 
were  considered  as  necessarily  fatal.  Larrey,  the  Surgeon-General 
of  Napoleon,  was  one  of  the  first  to  declare,  ' '  Plaies  de  I'estomac  ne 
sont  pas  mortelles  dans  tons  les  cas  "  (c/.  "Clinique  Chirurg.,"  tome 
IV,  p.  id),  which  was,  as  is  well  known,  confirmed  by  the  notable 
observations  of  our  countryman,  Beaumont,  on  Alexis  St.  Martin. 
Not  only  were  surgeons  timid  about  the  almost  unavoidable  peri- 
tonitis, but  there  existed  a  universal  belief  that  the  solving  and 
peptonizing  action  of  the  gastric  juice  prevented  the  wound  from 
healing.  The  observation  that  undoubted  gastric  ulcers  had  healed, 
and  that  gastric  fistulae  produced  by  physiologists  in  animals  healed 
spontaneously,  and  that  gastrotomy  and  gastrostomy  performed  in 
preantiseptic  years  had  not  shown  the  corrosive  effect  of  the  gastric 
juice,  paved  the  way  for  experiments  by  Gussenbauer  and  von  Wini- 
warter, proving  that  gastric  wounds,  when  sutured,  healed,  as  a  rule, 
without  interference  from  any  digestive  action  of  gastric  juice. 

The  first  proposition  to  treat  organic  gastric  diseases  by  operation 
was  made  by  Merrem,  who  originated  the  resection  of  the  pylorus 
(pylorectomy),  and,  after  performing  it'  on  dogs,  suggested  it  for 
human  beings  (Dan'l  C.  Theodor  Merrem,  "  Animadversiones  qusedam 
chirurg.  experim.,"  etc.,  Giessae,  1810).  This  writer  mentions  that 
a  Philadelphia  surgeon  had  already  attempted  pylorectomy  on  dogs 
and  rabbits,  but  had  been  unsuccessful. 

Gussenbauer  and  von  Winiwarter  demonstrated  later  that  this 
operation  was  technically  feasible,  and  that  removal  of  the  pylorus 
was  not  dangerous  to  life  ("von  Langenbeck's  Archiv,"  Bd.  xix,  S. 
347).  They  succeeded  in  showing  that  a  certain  percentage  of  cases 
of  pyloric  carcinoma  were  indications  for  this  operation.  Czerny 
and  Kaiser  confirmed  these  opinions,  and  the  latter  managed  to 
heal  and  keep  alive  a  dog  from  whom  he  had  excised  almost  the 
entire  stomach.  As  a  surgical  curiosity,  Haberkant  ("Arch.  f.  klin. 
Chirurg.,"  Bd.  Li,  Heft  in,  S.  484)  mentions  a  total  extirpation  of 
the  stomach  by  Dr.  Conner,  of  Cincinnati,  in  a  woman  fifty  3'ears  of 


350         SURGICAL   TREATMENT   OF    ORGANIC   GASTRIC   DISEASES. 

age,  who  died  before  the  esophagus  could  be  united  to  the  duodenum. 
This  operation  was  done  December  7,  1883,  and  was  the  first  attempt 
at  a  total  gastrectomy  recorded.  According  to  Rydygier,  a  surgeon 
named  Torelli,  in  1878,  executed  the  first  gastric  resection  in  a  man, 
removing  a  piece  sixteen  cm.  long  that  had  prolapsed  from  an  ab- 
dominal stab  wound  ("Centralbl.  f.  Chirurg.,"  1879,  S.  398).  In 
the  same  year  Billroth  brought  about  healing  of  a  gastric  fistula  by 
exposing  the  stomach  and  suturing  it  ("Wien.  med.  Wochenschr.," 
1 88 1,  S.  275).  In  January,  1881,  Billroth  executed  the  first  success- 
ful resection  of  the  pylorus  for  carcinoma. 

The  first  total  resection  for  ulcer  was  performed  by  Rydygier, 
and  the  first  partial  resection  for  ulcer  was  made  by  Czerny  in  1882. 
Both  were  successful.  Pean  executed  a  pyloric  resection  in  1879, 
before  Billroth,  and  so  did  Rydygier  in  1880,  but  both  were  unsuc- 
cessful. In  the  first  publication  of  Billroth's  resection  ("Wien. 
med.  Wochenschr.,"  1881,  No.  6)  Wolfler  defined  the  limits  of  the 
usefulness  of  total  resection  as  existing  in  the  transition  of  the  car- 
cinomatous tumors  to  the  pancreas  and  duodenum.  Cases  in  which 
the  carcinomatous  infiltration  extended  beyond  the  hepaduodenal 
ligament  should  be  excluded  from  resection.  From  these  indica- 
tions the  plan  to  a  second  operation  arose — "gastro- enterostomy," 
which  is  a  type  of  entero-anastomosis  (Maisoneuve),  an  artificial 
communication  between  the  stomach  and  the  jejunum,  when  the 
pyloric  obstruction,  for  reasons  given,  can  not  be  removed.  In 
1 88 1  (September  28th)  Wolfler  performed  this  operation  for  the 
first  time;  but  the  very  next  case  (performed  by  Billroth)  was  fatal, 
the  patient  dying  with  constant  emesis  of  bile.  The  necropsy 
showed  that  the  upward  traction  of  the  jejunal  loop  had  caused  what 
is  termed  a  "spur,"  which  returned  the  duodenal  secretions  (bile, 
etc.)  into  the  stomach.  The  spur  had  divided  the  artificial  gastro- 
intestinal lumen  into  two  unequal  parts,  of  which  the  larger  belonged 
to  the  duodenal  canal,  the  smaller  to  the  jejunal  loop  leading  away 
from  the  stomach. 

As  a  necessary  result  of  this  the  bile  and  pancreatic  juice  ran  into 
the  stomach,  while  nothing  could  pass  out  into  the  diminutive  dis- 
charging outlet.  In  one  of  Lauenstein's  cases  ("Verhandl.  d.  Deut- 
sch.  Gesell.  f.  Chirurg.,"  Thirteenth  Congress)  the  mesentery  of  the 
jejunal  loop,  which  had  been  drawn  up  to  meet  the  stomach,  com- 
pressed the  transverse  colon.  The  adducent  part  of  the  loop  was 
drawn  across  the  colon  like  a  tense  ridge.     Courvoisier,   in   1883, 


METHODS    OF    OPERATION.  351 

invented  another  method  calculated  to  avoid  these  difficulties.  In- 
stead of  inserting  the  jejunum  to  the  ventral  or  anterior  wall  of  the 
stomach,  he  made  a  slit  in  the  mesentery  of  the  transverse  colon  and 
inserted  the  loop  into  the  posterior  gastric  wall.  In  order  to  secure 
the  continued  onward  flow  of  the  bile  and  pancreatic  juice  through 
the  intestine,  Courvoisier  attached  the  adducent  part  of  the  intact 
loop  to  the  stomach  for  a  distance,  then  split  the  abducent  part,  and 
finally  sewed  the  wound  edges  of  the  gastro-intestinal  opening. 

In  1885  von  Hacker  described  a  similar  but  much  more  improved 
method,  which  consists  in  the  following :  The  colon  and  great  mesen- 
tery are  raised  upward ;  the  gaping  edges  of  the  slit  in  the  mesocolon 
are  attached  to  the  posterior  gastric  wall;  finally,  the  jejunal  loop  is 
attached  to  the  stomach  within  this  slit  (von  Hacker,  "Verhandl.  d. 
Deutsch.  Gesell.  f.  Chirurg.,"  1885,  Fourteenth  Congress). 

A  third  method  of  gastro- enterostomy  was  suggested  by  Billroth 
and  Brenner  ("Deutsche  Zeitschr.  f.  Chirurg.,"  Bd.  xxv,  p.  502). 
In  this  method  openings  are  made  both  through  the  gastrocolic 
ligament  and  mesocolon,  through  which  the  jejunal  loop  was  drawn 
up  and  sewed  to  the  anterior  gastric  wall  immediately  above  the 
greater  curvature.  Von  Hacker  has  given  these  various  operations 
very  significant  and  explicit  Latin  designations  ("Chir.  Beitr.  a.  d. 
Erzherzogin  Sophienspital  in  Wien,"  S.  42)-  These  are  his  terms  in 
English : 

1.  Gastro-enterostomy,  anterior,  antecolonic  (Wolfler). 

2.  Gastro-enterostomy,  posterior,  retrocolonic  (von  Hacker). 

3.  Gastro-enterostomy,  anterior,  retrocolonic,  Billroth-Brenner). 
A  number  of  other  modifications  must  be  passed  over,  since  we 

are  interested  only  in  the  clinical,  not  so  much  in  the  purely  sur- 
gical, aspect  of  the  subject; 

Since  the  publication  of  the  first  edition  of  this  work,  in  October, 
1897,  the  subject  of  the  "vSurgery  of  the  Stomach"  has  been  reviewed 
and  represented  in  the  "Cartwright  Lectures,"  published  in  the 
"Phila.  Med.  Journal,"  volume  i,  pages  829,  927,  1053,  and  1104. 
This  is  a  most  comprehensive  and  conservative  representation  of 
gastric  surgery,  by  one  of  the  ablest  operators  and  surgical  philoso- 
phers of  our  country,  Prof.  W.  W.  Keen. 

A  second  very  helpful  publication  bearing  directly  on  this  subject 
is  the  volume  by  Lindner  and  Kuttner— "Die  Chirurgie  des  Magens 
und  ihre  Indicationen  einschliesslich  Diagnostik." 

The  lectures  by  Prof.  Keen  contain  references  to  most  of  the  im- 


352         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

portant  American  and  English  works,  and  the  volume  of  Lindner  and 
Kuttner,  the  German  aspect  of  the  subject,  though  this  is  by  no 
means  neglected  in  the  former. 

An  excellent  French  representation  of  surgery  of  the  stomach  is 
by  Professors  F.  Terrier  and  Hartmann,  Paris,  1899. 


VARIOUS  FORMS  OF  OPERATIONS  PRACTISED  UPON  THE 

STOMACH. 

Gastrolysis  is  the  name  of  an  operation  by  which  peritoneal  ad- 
hesions binding  the  stomach  to  other  abdominal  organs  and  the 
abdominal  wall  are  severed.  The  symptoms  of  gastric  adhesions 
are  variable  and  obscure,  and  the  diagnosis  is  difficult.  The  most 
constant  symptoms  are:  (i)  A  long  history  of  digestive  suffering; 
(2)  persistent  pain;  (3)  persistent  vomiting;  (4)  displacement — in 
any  direction,  sometimes  even  upward.  In  one- third  the  cases  of 
adhesions  there  is  evidence  of  existing  or  previous  gastric  ulcer. 

The  author  referred  to  a  case  of  extensive  adhesions  in  the  first 
edition  of  this  work  (p.  695).  A  negro,  58  years  old,  had  been  suffer- 
ing from  the  most  intense  gastralgia,  and  vomiting  off  and  on  for 
twelve  years.  Distention  of  the  stomach  with  CO2  did  not  bring 
the  stomach  forward  and  out  from  the  arch  of  the  ribs.  The  electro- 
diaphane  showed  the  stomach  in  a  higher  position  than  normal. 
The  gastric  contents  showed  marked  hyperacidity.  An  operation 
was  undertaken  upon  advice  of  the  writer,  the  diagnosis  not  being 
established  definitely,  but  stated  as  probably  gastric  ulcer  with  per- 
foration. The  stomach  was  found  bound  to  the  diaphragm  by  two 
broad  adhesions,  to  the  transverse  colon  at  about  its  middle,  to  the 
liver  and  gall-bladder.  There  were  also  adhesions  between  the 
jejunal  loops  and  a  firm  adhesion  of  the  ascending  colon  to  the  ab- 
dominal wall.  The  adhesions  to  the  liver  and  gall-bladder  proved 
inseparable.  No  gastric  ulcer  was  discovered  at  the  operation,  but 
an  old  cicatrix  was  found  at  the  autopsy  two  months  after  operation- 

As  a  rule,  the  operation  is  successful.  Of  Lauenstein's  ten  cases, 
nine  recovered  ("Arch.  f.  klin.  Chir.,"  1892,  xlv,  121).  Other  suc- 
cessful operations  are  reported  by  Robson,  Naylor,  Ferrier,  Hoff- 
meister,  Billroth,  Mikulicz,  and  Hahn("Deutsch.  med.  Wochenschr.," 
1894,  No.  43).  The  adhesions  may  reunite  after  intersection  and 
cause  renewed  trouble. 

Gastrotomy  is  the  operation  of  opening  the  stomach  with  the 


GASTROSTOMY.  353 

object  of  removing  a  foreign  body;  then  sewing  up  the  wound  in 
the  stomach,  replacing  the  viscus,  and  sewing  up  the  external  ab- 
dominal wound.  This  operation  must  be  looked  upon  as  very  suc- 
cessful, for,  of  1 8  cases  reported  by  Henry  Morris  (Ashhurst,  "En- 
cyclopedia of  Surgery,"  vol.  v,  p.  589),  H  recovered.  This  opera- 
tion is  also  executed  with' a  view  to  effecting  dilatation  of  stricture  of 
the  esophagus  from  the  stomach  side;  and,  thirdly,  the  stomach  is 
opened  for  exploratory  purposes. 

Gastrostomy  is  designed  to  rescue  a  person  from  immediate  star- 
vation when  there  is  a  stenosis  in  the  esophagus,  either  from  cica- 
tricial contraction  resulting  from  esophageal  ulcer,  syphilitic,  tuber- 
culous, or  malignant  neoplasm,  or  corrosive  toxic  agents. 

Occasionally,  this  operation  may  be  required  by  tumor  outside 
the  esophagus.  Roswell  Park  ("International  Med.  Jour.,"  Jan. 
9,  1894)  and  Stockton,  also  Whitehead,  have  done  the  operation 
for  diverticulum  of  esophagus.  The  various  methods  of  technic  of 
this  operation  are  described  in  the  articles  of  W.  W.  Keen  {loc.  cit., 
p.  836).  Andrews,  Senn,  and  Stamm  are  American  surgeons  who 
have  described  new  methods  for  this  purpose. 

The  same  causes  affecting  the  cardia— for  instance,  carcinoma  of 
the  cardia— may  necessitate  gastrostomy.     Our  experience  is  that 
the  sooner  gastrostomy  is  performed  in  carcinoma  of  the  cardia, 
the  longer  is  the  life  sustained.     One  should  not  wait  until  nothing 
but  liquids  will  pass  the  stricture.     It  has  been  observed  that  the 
carcinoma  will  improve  and  show  some  tendency  toward  healing 
when  food  no  longer  passes  over  it  and  the  dilatation  above  the 
stricture  is  kept  clean  by  esophageal  lavage.     Whenever  possible, 
the  esophageal  dilatation  should  be  washed  out  daily,  even  after 
gastrostomy  has  been  performed.  -In  cases  where  the  esophageal 
stricture  had  become  impassable,  it  has  occasionally  been  noticed 
that  after  gastrostomy  the  stenosis  again  became  permeable,  and 
food  could  be  swallowed  for  a  while.     Witzel  has  devised  an  oblique 
entrance  of  the  fistula  into  the  stomach,  making  use  of  the  anatom- 
ical relations  of  the  abdominal  walls  for  that  purpose.     The  canal  is 
laid  partially  in  the  gastric  and  partially  in  the  abdominal  walls, 
being  somewhat  tortuous,  and  mostly  closed  to  food  trying  to  come 
outward  (Witzel,  "2.  Technik  d.  Magenfistelanlegung, "  "Central- 
blatt  f.  Chirurg.,"  189 1,  No.  32).     Von  Hacker's  technic,  as  original 
with  him,  has  been  practised  in  a  number  of  cases  for  dilating  esopha- 
geal strictures  with  sounds  introduced  from  the  gastric  side,  when 


354         SURGICAIv   TREATMENT   OE   ORGANIC    GASTRIC    DISEASES. 

dilatation  of  the  strictures  from  the  mouth  had  failed.  The  un- 
favorable results  of  gastrostomy — ^esas  reported  only  19.5  per  cent, 
of  so-called  recoveries  in  131  operations  ("Arch.  f.  klin.  Chirurg.," 
Bd.  xxxii) — are  largely  due  to  postponing  the  operation  until  the 
general  health  is  too  low  to  assist  in  recovery. 

Mikulicz  has  formulated  his  latest  results  in  the  following  table 
("Arch.  f.  klin.  Chirurgie,"  Bd.  li,  p.  9,  1895): 

GASTRECTOMY  AND  GASTROTOMY. 


Total. 

Recovered. 

Died. 

Mortality 
Percentage. 

For  simple  ulcer, 

I 

3 

I 

I 

I 
I 
0 

I 

0 
2 
I 
0 

0.0 

For  ulcer  and  hemorrhage,      

For  ulcer  with  perforation, 

Occlusion  of  pylorus  with  a  gall-stone,  .    . 

66.66 

100.00 

0.0 

Total, 

6 

3 

3 

50.0 

The  results  in  gastrostomy  for  esophageal  carcinoma  are  stated 
by  Mikulicz  (loc.  cit.)  as  follows:  Of  28  patients  that  survived  the 
operation  longer  than  three  weeks,  20  subsequently  died  of  the  funda- 
mental disease.  The  shortest  duration  of  life  was  three  and  one-half 
weeks,  the  longest  twelve  months,  after  the  operation.  The  average 
duration  of  life  after  the  operation  was  four  and  one-half  to  five 
months. 

GASTROSTOMY. 


Total. 

Recovered. 

Died. 

Mortality 
Percentage. 

Toxic,  corrosive  stricture  of  esophagus,    .    . 

Neurosis  (cardiospasm), 

Carcinoma  of  cardia  or  esophagus,     .... 

9 

I 
34 

9 
I 

28 

0 
0 
6 

0.0 

0.0 

17.64 

Total,         

44 

38 

6 

13-63 

Gastrorrhaphy,  or  gastroplication,  is  an  operation  for  closure 
of  wounds  of  the  stomach.  The  term  applies  to  any  case  where 
the  stomach  is  sewed ;  it  is  generally  restricted  to  those  cases  in  which 
a  limited  portion  of  the  gastric  wall  is  sutured  with  or  without  ex- 
cision. The  operation  is  available  as  a  means  of  reducing  excessive 
dilatations  not  complicated  by  malignant  neoplasm  and  which  have 
not  improved  under  persistent  and  careful  medical  treatment. 


PYLORECTOMY — RESECTION   OF   THE   PYLORUS.  355 

Pylorectomy,  or  Resection  of  the  Pylorus.*— In  considering  the 
value  of  this  operation  we  must  sharply  distinguish  between  three 
types  : 

1.  Typical,  total,  or  circular  pylorectomy. 

2.  Atypical  pylorectomy,  which  consists  of  a  combination  of  the 
former  with  a  gastro-enterostomy. 

3.  Partial  pylorectomy. 

Typical  or  Total  Pylorectomy. — Indications  in  259  operations  were 
the  following:  Carcinoma,   215  times;  ulcer  or  cicatrix,   34  times; 
sarcoma,  twice;  angioma  fibrosum,  once;  not  stated,  seven  times. 
In  judging  of  the  benefit  to  be  derived  from  these  operations,  we 
must  distinguish  sharply  between   (i)  the  immediate  and   (2)  the 
remote  results.     Generally  speaking,  surgeons  term  a  patient  "re- 
covered "  when  he  succeeds  in  getting  over  the  effects  of  the  opera- 
tion; this  is  the  immediate  result.     The  remote  results  are  deter- 
mined by  the  duration  of  life  after  the  operation.     The  immediate 
results  of  the  259  cases  above  enumerated  are  the  following:  Of  34 
cases  of  benign  stenosis,  23  recovered;  of  215  cases  of  carcinoma,  98 
recovered ;  both  cases  of  sarcoma  and  the  case  of  angioma  fibrosum 
recovered.     Haberkant   {loc.  cit.)  found  the  mortality  for  ulcer  to 
be  34.4  per  cent.,  and  for  carcinoma,  56.7  per  cent.,  in  a  total  of 
239  operations  performed  from  1879  to  1894.     It  is  a  very  important 
question  for  the  clinician  whether  the  mortality  is  becoming  less  as 
time  progresses,  which  signifies  an  improvement  in  the  technic  and 
knowledge  of  the  subject.     Haberkant  arranged  205  cases,  operated 
on  from '188 1  to  1894,  in  two  series  of  seven  years  each  (from  1881 
to  1888,  and  from  1888  to  1895).     In  the  first  series  the  total  mor- 
tality was  62.8  per  cent.;  in  the  second  series  it  was  45.1  per  cent. 
For  carcinoma  a  reduction  of  the  rate  of  mortality  from  65.4  per 
cent,  to  42.8  per  cent.,  and  for  benign  pyloric  stenosis  a  reduction 
from  42.8  per  cent,  to  27.7  per  cent.,  is  calculated.     In  1882,  of  13 
cases  of  resected  carcinomata,  all  died;  in  1893,  of  8  cases,  all  re- 
covered.    There  may  be  some  objection  to  the  absolute  correctness 
of  these  figures,  but  they  undoubtedly  admit  the  belief  that  our 


*  For  the  statistics  and  historical  information  on  the  subject  of  the  principal  operations 
we  are  indebted  to  the  "  Cartwright  Lectures,"  by  Professor  W.  W.  Keen,  "  Phila. 
Med.  Jour.;"  vol.  I,  p.  931,  and  to  an  article  by  Dr.  Haberkant  in  the  "Arch.  f. 
klin.  Chirurg.,"  Bd.  LI,  p.  861,  1896;  to  a  report  by  Prof.  J.  Mikulicz,  "  Arch.  f. 
klin.  Chirurg.,"  Bd.  LI,  p.  9,  1895;  the  volume  by  Lindner  and  Kuttner  ("  Magen 
Chirurgie,"  and  the  work  of  Terrier  and  Hartmann). 


356         SURGICAL   TREATMENT   OF    ORGANIC    GASTRIC    DISEASES. 

methods  of  diagnosis  and  operative  technic  are  improving.  Some 
forms  of  gastric  cancer  are  much  more  mahgnant  and  unfavorable 
to  treatment  than  others.  In  44  cases  in  which  microscopical  ex- 
aminations were  made,  we  found  the  following  comparisons: 


Nature  of  the  Gastric  Cancer. 

Number  of 
Operations. 

Recovered. 

Died. 

Scirrhus,       

16 

10 

9 

9 

10 

5 

I 

7 

6 

Adenocarcinoma  (epithelial  carcinoma),  .    . 
Medullary  carcinoma, 

5 
8 

Colloid  carcinoma, 

2 

44 

23 

21 

According  to  this  table,  colloid  carcinoma  is  the  most  favorable 
to  operation,  while  the  most  unfavorable  prognosis  is  to  be  formed 
of  medullary  sarcoma. 

The  remote  results  are  best  shown  in  the  duration  of  life  after 
the  operation,  which  is  expressed  in  the  accompanying  table  (see 
end  of  this  chapter),  from  which  it  is  evident  that  the  average  ex- 
pectation of  life  after  pylorectomy  for  carcinoma  is  not  very  long. 
For  of  twenty-six  so-called  recoveries,  or  immediate  good  results, 
seventeen,  or  nearly  two-thirds,  died  within  one  year  after  the  opera- 
tion. Furthermore,  of  twenty-six  (different)  cases,  twelve  died  in 
from  one  and  one-half  to  thirteen  months  from  return  of  the  mahg- 
nant trouble  or  metastases.  One  case  of  Billroth's  lived  five  and  a 
quarter  years.  One  case  of  Kocher  ("Centralbl.  f.  Chir.,"  1894,  S. 
221)  lived  five  years  and  four  months,  and  one  case  of  Rattimmow's 
(ibid.,  S.  10 14)  lived  eight  years.  Wolfler  cites  three  cases  who  lived 
over  four  years,  four  over  five  years,  one  over  six  years,  and  two  over 
eight  years.  The  boundary  of  the  pathological  tissue  can  not  be 
determined  accurately.  As  is  the  custom  in  most  mahgnant  neo- 
plasms of  other  organs,  the  resection  is  made  by  cutting  through  the 
apparently  or  visibly  healthy  tissue  one  cm.  from  the  limit  of  the 
diseased  portion.  Czerny,  however,  found,  by  careful  microscopical 
examination  of  resected  pieces,  that  the  edges  of  the  section,  made 
through  apparently  healthy  tissue,  contained  cancerous  alveoli;  he 
therefore  advised  that  the  cut  be  made  not  one,  but  three,  cm.  from 
the  limit  of  the  carcinomatous  tissue.  Virchow  holds  that  as  long 
as  a  neoplasm  is  solitary,  the  hope  for  a  successful  operation  must 
not  be  given  up. 


INDICATIONS    FOR    OPERATION.  357 

Pylorectomv  is  the  only  operation  which  can  make  a  definite 
cure  or  a  recovery  of  some  duration  possible;  and  although  the 
prospects  of  complete  cure  are  very  few,  we  must  hold  fast  to  the 
encouragement  which  statistics  furnish — namely,  that  more  cases 
recover  with  improvement  in  the  technic  and  the  possibilit}^  of  early 
diagnosis.  Haberkant  {loc.  cit.,  p.  26)  takes  too  gloomy  a  view  of  the 
future  of  gastric  operations  when  he  asserts  that  we  must  expect  no 
advance  in  the  curability  of  carcinoma,  because,  in  his  opinion, 
patients  decide  for  the  operation  too  late,  even  after  the  diagnosis  is 
certain;  and,  secondly,  because  it  will  be  impossible  to  diagnose 
gastric  carcinoma  at  a  time  when  a  cure  by  extirpation  would  be 
possible.  The  early  diagnosis  of  gastric  carcinoma,  he  emphasizes, 
is  in  almost  all  cases  impossible  (?).  The  surgeon,  as  a  rule,  con- 
cludes to  operate  only  when  distinct  stenotic  symptoms  are  present, 
with  emesis,  dilatation,  and  palpable  tumor.  The  only  sign  which 
Haberkant  cites  to  be  doubtful — that  is,  the  absence  of  HCl  in  the 
gastric  contents — is  by  no  means  the  only  one  the  clinician  has  to 
be  guided  by,  as  reference  to  the  chapter  on  Diagnosis  of  Gastric 
Carcinoma  will  show.  In  justice  to  the  surgeons,  we  desire  to  say 
that  they  are  not  given  the  cases  early  enough  and  the  clinicians 
can  not  be  exempt  from  blame  for  this  delay  in  operation. 

There  can  not  be  a  moment  of  doubt  about  the  feasibility  of  opera- 
tion when  gastric  dilatation  is  manifestly  due  to  palpable  neoplasm, 
even  if  it  were  not  malignant.  But  we  generally  advise  operation 
in  case  (i)  dilatation  is  associated  with  cachexia;  (2)  absence  of  HCl 
in  the  gastric  contents;  (3)  excess  of  lactic. acid;  (4)  presence  of  the 
Oppler-Boas  bacillus.  Professor  W.  W.  Keen,  in  quoting  these 
deciding  factors  from  this  work  ("Phila.  Med.  Journal,"  vol.  i,  p. 
932),  adds  (5)  when  age  is  past  forty  years;  (6)  when  hematemesis 
is  present;  (7)  when  examination  of  blood  shows  a  diminution  in  red 
corpuscles  and  hemoglobin,  and  the  digestive  leukocytosis  is  absent. 
Stenotic  symptoms,  accompanied  by  these  signs,  are  indications  for 
operation,  even  in  the  absence  of  palpable  tumor.  Personally,  I 
always  urge  operation  when  the  first  three  conditions  are  persistently 
present  and  the  case  does  not  improve  after  three  weeks  of  appro- 
priate treatment. 

Exploratory  laparotomy,  which  Haberkant  states  to  be  the  only 
reliable  means  for  making  an  early  diagnosis  of  carcinoma,  should 
be  encouraged  by  the  internist,  not  because  carcinoma  can  be  diag- 
nosed with  certainty  thereby,  for  it  really  can  not,  as  the  stomach 


358         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

is  the  seat  of  many  kinds  of  neoplasms,  and  even  ulcer,  with  indu- 
rated edges,  may  simulate  carcinoma;  so  that  the  finding  of  a  new 
growth  does  not  include  a  knowledge  of  its  exact  nature,  and  if  a 
carcinoma  of  small  size  be  at  the  posterior  side  of  the  lesser  curva- 
ture, it  may  escape  attention  even  at  autopsies  until  the  stomach  is 
removed  from  the  body.  The  article  quoted  is  an  excellent  piece 
of  work,  and  the  pessimistic  view  on  the  future  development  of 
clinical  diagnosis  need  not  discourage  the  clinician;  for  the  prog- 
ress which  digestive  physiolog}^  pathology,  and  bacteriology  have 
made  in  the  last  twenty  years,  and  are  still  making,  strengthens  the 
belief  that  we  shall,  in  the  near  future,  be  able  to  make  early  diag- 
noses of  gastric  neoplasms.  AA'^hether  they  will  be  operable  or  not  is 
another  question,  which  the  clinician  and  the  surgeon  must  investi- 
gate together. 

The  practitioner  should  not  be  too  guarded  in  advising  explorators^ 
laparotomy  in  cases  of  rapidly  developing  cachexia  and  emaciation 
with  the  symptoms  of  chronic  gastritis  and  absence  of  HCl.  Tenta- 
tive treatment  should  not  be  prolonged  over  three  weeks.  It  is  not 
near  so  serious  a  fault  to  have  caused  the  opening  of  a  stomach  and 
found  nothing  operable,  as  to  permit  a  case  to  continue  and  find  out, 
at  the  autopsy  only,  that  it  was  a  circumscribed  carcinoma  the  re- 
moval of  which  might  have  prolonged  life  for  years.  The  author 
has  been  responsible  for  three  exploratory  laparotomies  at  which 
nothing  was  found,  although  cancer  was  suspected  in  one  and  ulcer 
in  the  other  two.  The  cases  recovered  and  were  cured  of  their  symp- 
toms, of  pain  and  vomiting.  One  of  these  cases  had  vomited  a  pint 
of  blood  in  the  presence  of  the  writer.  At  the  operation,  by  Dr.  J. 
M.  T.  Finney,  nothing  abnormal  could  be  found  in  the  stomach. 

Even  after  the  diagnosis  is  certain,  much  foresight  is  necessary 
in  selecting  cases  for  operation;  the  establishment  of  the  indication 
must  be  done  with  exactness  and  care.  That  the  mortality  from 
cancer  resections  has  sunk  from  65.4  per  cent,  in  the  period  from 
1879  to  1887  to  42.8  per  cent,  in  the  period  from  1888  to  1894,  and 
of  benign  stenosis  from  42.8  per  cent,  to  27.7  per  cent,  in  the  same 
period,  shows  that  the  importance  of  exact  "Indicationsstellung" 
is  being  appreciated. 

How  many  pyloric  carcinomata  are  operable?  In  the  records  of 
the  Vienna  Pathological  Institute,  from  1817  to  1873,  Gussenbauer 
and  von  Winiwarter  found  accounts  of  542  pyloric  cancers,  of  which 
223  were  entirely  isolated,  and  172  of  these  showed  no  adhesions; 


STATISTICS    OF    OPERABLE    CASES.  359 

SO  41. 1  per  cent,  were  free  from  metastases,  and  37.7  per  cent,  were, 
in  addition  to  this,  free  from  adhesions — the  latter  were  suited  for 
resection.  In  many  of  the  instances  where  the  necropsy  showed 
adhesions  there  must  have  been  a  time  when  they  were  not  present; 
so  that  a  big  field  for  operative  therapy  is  opened.  Streit  found,  at 
the  Bern  Pathological  Institute,  that  25.9  per  cent.  ("Deutsche 
Zeitschr.  f.  Chir.,"  Bd.  xvi)  and  Kramer  (Konig,  "lychrb.  d.  spec. 
Chir.,"  Bd.  11)  that  33.3  per  cent,  of  pyloric  cancers  were  operable. 
The  best  statistics  state  that  from  one-quarter  to  one-third  of  these 
neoplasms  are  operable.  Adhesions  increase  the  mortality ;  in  sixty- 
six  cases  of  pylorectomy  in  which  records  were  kept  concerning  this 
point,  the  mortality  was  72.7  per  cent,  with,  and  27.2  per  cent, 
without,  adhesions.  No  immediate  recoveries  are  on  record  where 
there  were  adhesions  of  the  pylorus  with  the  transverse  colon,  or 
with  the  colon  and  the  pancreas  together.  Two  patients  with  tumors 
of  the  curvatures  and  fundus,  although  distinctly  ascertained  to  be 
malignant  (they  were  causing  no  stenotic  symptoms;  so  that  the 
vicarious  digestion  of  the  intestines  maintained  the  nitrogen  equi- 
librium sufficiently),  lived  longer — not  being  operated — than  two  in 
whom  gastro-enterostomy  was  performed.  Both  operated  cases  had 
adhesions.  In  the  non-operated  cases  there  were  no  adhesions  found 
at  autopsy — that  is  to  say,  the  average  duration  of  life  after  the  date 
of  exact  diagnosis  was  longer  in  those  cases  of  this  type  that  were 
not  operated  than  in  those  that  were. 

Can  the  secretory  and  motor  function  be  restored  after  total  ex- 
tirpation of  a  malignant  tumor? 

Obalinski  and  Jaworski  ("Wien.  klin.  Wochenschr.,"  1889,  No.  5), 
Rosenheim  ("Deutsche  med.  Wochenschr.,"  1892,  No.  49),  Kansche 
(ibid.),  and  Zawadski  and  Sohnan  ("Deutsche  med.  Wochenschr.," 

1894,  No.  8)  assert  that  secretion  is  not  restored  by  pylorectomy, 
but  the  last-mentioned  authors  assert  that  the  motility  may  again 
become  good.  In  cases  that  are  operated  before  a  complete  destruc- 
tion of  the  gland-cells  has  taken  place,  the  lost  secretion  of  HCl  has 
been  observed  to  be  restored.  Rosenheim  ("Berlin,  klin.  Woch- 
enschr.,"  1895,  No.   i)  and  Boas  ("Deutsche  med.  Wochenschr.," 

1895,  No.  5)  have  reported  the  only  two  cases  of  this  kind;  so  that  it 
must  be  an  extremely  rare  occurrence. 

Pyloric  stenosis  caused  by  simple  benign  adhesions  can  be  re- 
moved by  severing  the  constricting  bands.     These  adhesions  may 
cause  pain  and  hematemesis  without  gastrectasia,  as  was  shown  in 
24 


360         SURGICAL   TREATMENT    OF    ORGANIC   GASTRIC   DISEASES. 

a  case  of  Hahn's  ("Deutsche  med.  Wochenschr.,"  1894,  No.  43), 
where  laparotomy  revealed  five  adhesions  binding  the  stomach  to  the 
colon.  He  ligated  each  one  of  the  strong  bands  doubly  and  severed 
it,  and  from  that  moment  the  patient  recovered  perfectly.  Median 
hemise  of  the  linea  alba  have  been  known  to  cause  intense  gastric 
suffering,  necessitating  operation.  Rosenheim  has  described  such 
cases,  which  were,  however,  much  benefited  by  lavage  and  diet,  so 
that  the  motor  insufficiency  was  much  improved  ("Berlin,  klin. 
Wochenschr.,"  1897,  No.  11).  Preperitoneal  lipomata  have  been 
known  to  cause  interference  with  the  motility  and  necessitate  surgical 
interference.  Adhesions  may  reunite  after  intersection  and  cause 
renewed  trouble,  as  was  shown  in  one  case  of  Hahn's,  in  which 
the  adhesions  were  divided  again  by  W.  Levy  two  years  after  the 
first  operation;  a  few  months  after  this  Hadra  executed  a  gastro- 
enterostomy, on  Rosenheim's  suggestion  {loc.  cit.),  which  gave  no 
perfect  relief,  as  the  two  previous  operations  had  caused  new  adhe- 
sions. Referring  again  to  malignant  tumors  of  the  lesser  or  greater 
curvatures  where  good  motility  is  maintained,  and  that  cases  of  this 
kind  which  are  not  operated  may  live  a  year  or  more,  we  might  add 
the  case  of  a  lady  in  whom  Musser  and  Da  Costa  diagnosed  a  palpable 
tumor  in  February,  1896.  Personally,  we  determined  the  location 
in  July,  1896,  when  there  was  complete  loss  of  all  secretion  and 
numerous  Oppler-Boas  bacilli  were  present  in  the  gastric  contents. 
A  fragment  of  the  neoplasm  was  obtained  in  September,  1896,  during 
lavage,  clinching  the  diagnosis  of  carcinoma.  With  daily  lavage 
with  HCl  solution  (4:1000),  highly  nutritious  and  concentrated 
diet,  rest,  and  internal  use  of  HCl,  condurango,  and  strychnin,  this 
patient  has  gained  twelve  pounds  in  six  months,  and  is  still  (Septem- 
ber, 1897)  able  to  take  walks  of  two  miles  a  day — nineteen  months 
after  Musser  first  diagnosed  the  existence  of  a  gastric  tumor.* 

The  number  of  authoritative  advocates  of  pylorectomy  for  benign 
stenosis  is  growing  smaller  and  smaller.  Von  Hacker  recently  again 
emphasized  that  gastro -enterostomy  is  not  used  enough  for  the 
treatment  of  cicatricial  stenoses  of  the  pylorus  and  duodenum,  and 
that  it  has  the  value  of  a  radical  operation  for  many  cases  without 
sharing  its  dangers  (von  Hacker, "  Magenoperationen, "  etc.,  published 

*  This  case  lived  eighteen  months  after  establishment  of  diagnosis  by  the  author.     At 

one  time,  July,  1896,  operation  was  strongly  advised,  but  refused.  The  great  difficulty 
with  such  cases  is  that  the  location  of  the  tumor  can  not  be  determined  with  certainty. 
Exploratory  laparotomy  is  safest  for  dingnosis. 


PARTIAL   PYLORECTOMY.  36 1 

by  William  Braumiiller,  Wien,  1895).  Mintz  considers  pylorectomy 
unjustifiable  for  benign  cicatricial  stenoses  ("Zeitschr.  f.  klin.  Med.," 
Bd.  XX  v) .  For  mild  stenotic  cicatrices  the  pyloroplastic  operation  has 
proved  sufficient.     We  shall  refer  to  this  operation  in  the  following : 

Atypical  pylorectomy  was  executed  first  in  1885,  by  Billroth.  It 
is  a  combination  of  resection  of  the  pylorus  with  gastro-enterostomy 
recommended  in  cases  where  carcinomata,  although  operable,  had 
so  extensively  involved  the  gastric  walls  that  after  resection  it  was 
impossible  to  suture  the  remainder  of  the  stomach  to  the  duodenum, 
or  where  traction  upon  the  duodenum  to  meet  the  stomach  would 
produce  too  much  tension  upon  the  stitches,. 

Von  Biselsberg  executed  the  most  extensive  atypical  resection  of 
the  pylorus  in  a  very  large  but  sharply  limited  carcinoma.  His  in- 
cision began  close  to  the  cardia  and  descended  perpendicularly 
downward,  so  that  only  a  small  portion  of  the  left  fundus  remained 
("von  Langenbeck's  Archiv,"  Bd.  xxxix).  Even  this  incision  was 
not  through  healthy  tissue,  and  the  stitches  tore  through,  terminating 
the  case  by  perforation  peritonitis.  In  twenty  cases  of  atypical 
pylorectomy  eight  died — a  mortality  of  forty  per  cent.  The  first 
case  of  immediate  success  b}^  Billroth  succumbed  to  a  recurrence 
after  four  months.  KJronlein  performed  this  operation  for  trau- 
matic cicatricial  stenosis  extending  into  the  duodenum. 

Partial  Pylorectomy  and  Partial  Resections  of  the  Gastric  Walls. — 
The  indications  are  given  by  the  round  ulcer,  both  on  the  anterior 
and  posterior  walls,  cicatrices  that  produce  interference,  or  tumors 
of  the  neighborhood  that  have  extended  to  the  gastric  wall  without 
involving  the  entire  circumference  of  the  pylorus.  Partial  pylorec- 
tomy preserves  the  valvula  pylori,  which  is  itself  rarely  the  seat  of 
gastric  ulcer.  In  a  total  pylorectomy  the  sphincter  and  valve  are 
removed  entirely  and  replaced  by  a  gradually  contracting  scar. 
Haberkant  records  eight  such  partial  operations — three  by  Billroth 
(reported  by  von  Hacker,  loc.  cit.),  three  by  Czerny  ("Beitr.  z.  klin. 
Chir.,"  Bd.  ix,  1892),  one  by  Spear  ("Centralbl.  f.  klin.  Chir.,"  1885), 
and  one  by  Schuchardt  (Twenty-third  German  Surgical  Congress, 
1894). 

Billroth's  and  Spear's  cases  all  died;  the  three  cases  of  Czerny 
recovered.  The  indications  in  the  cases  of  the  first  two  surgeons 
were:  cicatrices,  four  times  in  the  anterior  pyloric  wall.  The  indica- 
tions in  the  last  three  cases  by  Czerny  were :  ulcer,  once ;  extension 
of  sarcoma,  twice.     The  case  of  stenosing  ulcer,  operated  upon  by 


362         SURGICAL   TREATMENT   OF    ORGANIC    GASTRIC    DISEASES. 

the  latter  by  this  method,  was  still  doing  well,  according  to  last 
reports,  ten  years  after  the  operation. 

The  case  of  Schuchardt's  is  most  instructive  in  bearing  out  our 
objection  to  Haberkant's  assertion  that  exploratory  laparotomy  is 
the  only  reliable  means  for  early  diagnosis  of  carcinoma.  Schuch- 
ardt's case  had  two  open  ulcers,  only  one  of  which  was  discovered 
when  the  stomach  was  opened,  located  at  the  lesser  curvature  and 
removed  by  excision  of  a  piece  as  large  as  a  25-cent  piece.  Although 
no  peritonitic  symptoms  appeared,  death  occurred  under  progressive 
cachexia  in  fourteen  days.  The  necropsy  showed  a  second,  much 
larger  ulcer,  which,  in  Haberkant's  (loc.  cit.,  p.  514)  own  words,  was 
not  only  inoperable,  but  could  not  even  be  palpated.  If  a  very 
large  ulcer  can  not  be  palpated  when  the  stomach  is  exposed,  ex- 
ploratory laparotomy  is  not  infallible  as  a  diagnostic  method ;  it  may 
desert  us  like  our  clinical  methods.  The  oldest  resections  of  the  gastric 
wall  are  by  Billroth  ("Wien.  med.  Wochenschr.,"  1881,  p.  275)  and 
Esmarch  (quoted  by  Wolfler,  loc.  cit.),  for  the  repair  of  fistulae. 

Rupp  resected  a  subserous  leiomyoma  of  the  anterior  wall  near 
the  cardia  in  this  way  ("von  Langenbeck's  Arch.,"  Bd.  XL,  p.  756). 
The  number  of  partial  resections,  including  both  those  of  the  pylorus 
and  of  the  anterior  gastric  wall,  amount  to  fifteen  operations;  eight 
were  cured,  seven  were  fatal,  giving  a  mortality  of  46.6  per  cent. 

Total  Gastrectomy. — In  1897  Schlatter  reported  the  first  com- 
plete gastrectomy  anatomically  proved  as  such  ("N.  Y.  Med.  Rec," 
December  25,  1897,  lii,  909).  The  operation  was  performed  Septem- 
ber 6,  1897.  The  patient  lived  one  year  and  two  months,  dying 
October  29,  1898.  Death  was  due  to  multiple  carcinomatous  meta- 
stases, and  was  not  ascribed  to  inanition.  Brigham  (' '  Boston  Med. 
and  Surg.  Jour.,"  May  5,  1898)  reported  a  complete  removal  of  the 
entire  stomach  for  carcinoma,  and  anastomosing  the  duodenum  to 
the  esophagus  by  the  Murphy  button.  Brigham's  case  was  still 
doing  well  in  June,  1899.  MacDonald  ("Jour.  Am.  Med.  Assoc," 
September  3,  1898)  and  Richardson  ("Boston  Med.  and  Surg.  Jour.," 
October  20,  1898)  have  reported  successful  gastrectomies.  A  case 
of  gastrectomy  reported  by  Summa  and  Bernays  ("Jour.  Am.  Med. 
Assoc,"  February  12,  1898)  died  thirty-six  hours  after  operation. 
W.  W.  Keen  (loc.  cit.)  concludes  that  abstention  from  such  extensive 
operations  is  the  wiser  course  to  pursue.  The  author  has  already 
pointed  out  that  nothing  new  has  been  added  to  our  knowledge  of 
the  physiology  of  the  stomach  by  Schlatter's  investigations  (Hem- 


GASTRO-KNTEROSTOMY.  363 

meter,  "New  York  Med.  Record,"  Liii,  p.  409,  March,  1898).  That 
digestion  and  metaboHsm  would  go  on  normally  for  a  limited  time 
in  the  absence  of  the  stomach  was  known  long  before  Schlatter's 
operation. 

Gastro-enterostomy. — In  the  beginning  of  this  chapter  we  de- 
scribed the  various  (three  main)  types  of  this  operation  that  have 
been  suggested.  Which  of  these  types  of  operation — Wolfler's, 
von  Hacker's,  Billroth-Brenner's,  or  any  of  the  other  methods  de- 
scribed in  modem  text-books  on  abdominal  surgery — is  to  be 
selected  is  a  matter  to  be  decided  by  the  surgeon.  But  we  would 
remark  in  parenthesis  that  the  physiological  rotation  of  the  full 
stomach  around  its  long  axis,  whereby  the  large  curvature  is  turned 
anteriorly  and  the  smaller  posteriorly,  which  is  asserted  by  Tiede- 
mann,  has  been  confirmed  by  no  other  experimenter.  Betz  and 
lycsshaft  ("Virchow's  Arch.,"  1882,  vol.  lxxxvii)  have  opposed  the 
view.  In  many  hundreds  of  experiments  on  the  full  stomachs  of 
animals  for  the  study  of  the  peristalsis  we  have  never  observed  it, 
and  even  if  it  were  observed  when  the  abdomen  is  opened,  it  could 
not  then  be  considered  physiological.  The  hypothetical  gastric 
rotation  has  been  adduced  as  an  objection  to  Wolfler's  anterior 
antecolonic  operation,  on  the  ground  that  the  artificial  lumen  be- 
tween stomach  and  intestine  was  compressed  by  bringing  the  loop 
between  the  abdominal  wall  and  the  stomach  during  this  rotation. 
Von  Hacker's  method  does  avoid  spur  formation,  and  thereby  retro- 
flux  of  duodenal  contents  into  the  stomach,  and  also  compression 
of  the  transverse  colon  by  the  inserted  jejunal  loop.  In  addition 
to  this  the  entire  intestinal  canal  remains  unchanged  in  its  natural 
anatomical  relations.  Von  Hacker  himself  states  that  the  mortality 
is  not  materially  reduced  by  his  method.  The  functional  results 
are  claimed  by  most  German  surgeons  to  be  better  with  von  Hacker's 
operation.  Chlumskij  collected,  in  all,  550  gastro-enterostomies 
("2^eitschr.  f.  klin.  Chir.,"  1898,  xx,  231).  According  to  his  table,  the 
mortality  in  231  cases  operated  by  the  Wolfler  method  was  38.09 
per  cent.;  of  152  cases  by  the  von  Hacker  method,  32.52  per  cent. 
In  the  latter  method  the  escape  of  gastric  contents  into  the  intestine 
is  facilitated  by  gravity. 

Results. — In  388  cases  Haberkant  found  the  total  mortality  to  be 
41.5  per  cent.  For  gastro-enterostomy  for  carcinoma  it  was  43.5 
per  cent. ;  for  ulcer,  25.5  per  cent.  One  of  the  indications  of  gastro- 
enterostomy is  the  simple  atonic  dilatation.     Four  such  operations 


364         SURGICAI.   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

are  reported,  one  of  which  (Selenkow)  died  and  the  remaining  three 
(Renton,  von  Kleef,  and  Jeannel)  recovered  and  the  functional  re- 
sult was  good.  Concerning  the  remote  results,  it  is  self-evident 
that  in  carcinoma  they  can  not  be  of  long  duration,  as  the  growth 
is  left  intact;  nevertheless  the  table  at  the  end  of  this  article  shows 
ten  cases  in  which  the  recover}^  lasted  over  a  year.  A  singular  gastro- 
enterostomy is  that  reported  by  Hahn  ("Berlin,  klin.  Wochenschr.," 
1894,  p.  1097).  The  operators  were  convinced  that  the  neoplasm 
was  a  carcinoma ;  the  patient  lived  seven  years  after  the  operation 
without  complaints,  the  tumor  always  being  palpable.  This  case 
will  always  remain  a  doubtful  one. 

Robert  F.  Weir  has  attempted  to  prove  statistically  that  gastro- 
enterostomy keeps  patients  with  pyloric  carcinoma  alive  as  long  as 
pylorectomy,  whereas  the  mortality  is  in  the  proportion  of  twelve 
per  cent,  for  the  former  to  fifty-two  per  cent,  for  pylorectomy. 

Haberkant's  statistics  of  a  much  larger  number  of  cases  show  a 
mortality  of  54.4  per  cent,  for  resection  to  43.5  per  cent,  for  gastro- 
enterostomy. But  then  many  cases  have  formerly  been  resected  that 
would  in  the  present  advanced  state  of  knowledge  not  have  been 
operated.  Pylorectomy  gives  a  better  prospect  for  more  lasting 
recovery  than  gastro-enterostomy.  Of  forty-seven  cases  recovered 
from  pylorectomy,  twenty-two  lived  longer  than  one  year  after  the 
operation ;  but  of  fifty-eight  cases  of  gastro-enterostomy,  only  twelve 
lived  longer  than  one  year.  With  the  exception  of  Hahn's  doubtful 
case,  there  is  no  gastro-enterostomy  in  which  the  recovery  lasted 
longer  than  two  3^ears;  but  of  Haberkant's  collected  successful 
pylorectomies,  twelve  lived  longer  than  two  years. 

Pyloroplastic  Surgery  (Pyloroplasty). — This  operation  was 
first  devised  by  von  Heinecke,  in  March,  1886.  The  first  operation 
was  a  success.  In  February,  1887,  Mikulicz  rediscovered  and  applied 
the  method  independently  of  von  Heinecke.  The  operation,  which 
is  applicable  to  some  pyloric  cicatrices,  is  carried  out  b}^  slitting 
open  the  scars  longitudinally  in  the  line  of  the  pyloric  lumen  and 
pulling  the  wound-edges  apart  by  hooks  inserted  in  the  middle; 
then  they  are  reunited  by  sutures  transversely.  Graphically,  the 
procedure  is  expressed  thus : 


DIGITAL   DIVULSION    OF    THE    PYLORUS.  365 

Cases  have  been  reported  in  which  pyloroplastic  surgery  was 
attempted,  and,  faihng,  a  pylorectomy  had  to  be  done  (Lobker, 
"Verhandl.  des  XXI.  Deutsch.  Chir.  Kongresses,"  i,  60).  Czerny 
reported  a  case  in  which  resection  had  to  be  done  because  the  scar 
was  so  rigid  it  could  not  be  unfolded  ("Beitrage  z.  klin.  Chir.,"  Bd. 
IX,  1892,  p.  678).  The  cases  that  recover  from  a  successful  opera- 
tion of  this  kind  are,  as  a  rule,  cured  permanently;  no  return  of 
pyloric  stenosis  has  been  reported. 

Up  to  1894  (inclusive),  51  operations  of  this  type  have  been  com- 
piled, 40  of  which  were  successful  and  1 1  fatal,  making  a  mortahty 
of  21.5  per  cent.  In  44  instances  where  the  indication  was  stated, 
there  were  7  peptic  ulcers  and  37  cicatricial  stenoses;  but  of  these 
37  scars,  14  were  produced  by  corrosive  poisons.  The  combined 
tables  of  Bavton  and  Bull  ("New  York  Med.  Rec,"  May  25  and 
June  8,  1889)  contain  28  cases,  with  a  mortality  of  31.  i  per  cent. 

Digital  Divulsion  of  the  Pylorus.— Loreta's  operation  consists 
of  a  simple  gastrotomy  and  subsequent  gradual  expansion  of  the 
pylorus,  by  introducing  first  one  and  then  two  fingers ;  the  dilating 
forceps  has  been  used  for  the  same  purpose.  Hahn  recommended 
that  the  anterior  wall  of  the  stomach  should  be  invaginated  upon 
the  finger  and  carried  into  the  opening  of  the  p^dorus.  The  dangers 
of  the  procedure  consist  in  (i)  rupture  or  production  of  hemorrhages 
by  lesions  of  the  gastric  wall,  (2)  frequent  return  of  the  stenosis. 

According  to  Bull  ("Centralbl.  f.  Chir.,"  1890,  S.  149),  Toreta 
himself  has  had  the  return  occur  in  three  cases.  Haberkant  (loc. 
cit.)  has  compiled  31  cases  of  Loreta  operations,  with  19  cures  and 
12  deaths— a  mortality  of  38.7  per  cent.  Three  of  the  fatal  opera- 
tions were  for  carcinomata. 

Novara  had  to  execute  a  resection  after  divulsion  had  failed ;  the 
only  justifiable  indication  is  cicatricial  stenosis.  The  operation  has 
few  advocates,  and  will  have  to  give  way  to  more  exact  and  reliable 
operative  methods. 

For  atonic  forms  of  dilatation  that  resist  all  medical  treatment, 
Heinrich  Bircher,  of  Aarau,  Switzerland,  has  devised  a  new  opera- 
tion, called  gastroplication.  This  surgeon  attempted  to  improve 
the  motility  of  the  stomach  by  a  reduction  of  its  size  through  making 
a  fold  or  plait  in  the  gastric  wall.  The  greater  curA^ature  is  raised 
to  a  much  higher  level  by  this  operation.  Bircher  obtained  good 
results  in  three  cases,  one  of  which,  however,  died  three  months 
after  the  operation.     A  certain  amount  of  muscular  tonicity  must 


366         SURGICAL   TREATMENT   OP    ORGANIC   GASTRIC   DISEASES. 

still  be  left  in  order  to  make  this  operation  even  a  partial  success 
("American  Jour.  Med.  Sciences,"  1892,  vol.  cm,  p.  333).  The 
operation  has  not  as  yet  been  repeated  in  a  sufficiently  large  number 
of  cases  to  permit  of  a  correct  judgment  of  its  real  value. 

Weir  ("New  York  Med.  Jour.,"  July  9,  1892),  unaware  until  two 
days  before  the  operation  that  Bircher  had  preceded  him,  did  a 
similar  operation,  but  united  the  two  layers  of  the  gastric  wall  by 
four  successive  rows  of  interrupted  sutures,  the  final  one  uniting 
the  greater  curvature  to  the  lesser.  Keen  {loc.  cit.)  considers  the 
technic  of  Weir  a  decided  improvement  over  Bircher's.* 

Gastropexy  is  the  name  of  an  operation  for  the  relief  of  gastro- 
ptosis,  by  suturing  the  stomach  to  the  anterior  abdominal  wall. 
The  stomach  is  not  opened  during  the  operation.  Duret  ("Revue 
de  Chir.,"  1896,  xvi,  421)  reports  a  successful  case.  Davis  modified 
the  technic  somewhat  and  reported  two  successful  cases  ("Western 
Med.  Rev.,"  Oct.,  1897). 

Treves  described  a  case  of  hepatoptosis,  gastroptosis,  and  general 
enteroptosis  brought  about  by  adhesions  of  the  omentum  to  old  cal- 
careous, tuberculous  glands  in  the  mesentery  of  the  ileum  and  lying 
in  the  right  iliac  fossa.  The  glands  were  removed  and  the  liver 
sewed  firmly  to  fibrinous  tissues  around  the  ensiform  cartilage. 
The  adhesions  of  the  omentum  which  had  drawn  the  organs  down 
were  loosened,  which,  together  with  the  hepatopexy,  restored  the 
stomach  and  colon  to  their  places.  The  patient  recovered  entirely 
after  having  suffered  for  six  years. 

Gastroplasty,  gastro-anastomosis,  and  gastro-gastrostomy 
are  operations  for  the  relief  of  hour-glass  stomach.  Fifteen  opera- 
tions of  this  kind  have  been  done  (W.  W.  Keen,  loc.  cit.).  In  two 
of  them  radical  relief  could  not  be  given  by  the  operation.  Of  the 
remaining  thirteen  cases,  twelve  were  successful. 

Gastro-anastomosis  is  an  operation  first  performed  by  Wolfler 
for  hour-glass  stomach,  by  which  one  portion  of  the  organ  is  anasto- 
mosed with  the  other  at  the  greater  curvature.  Gastro-anastomosis 
remedies  the  separation  of  the  organ  into  two  distinct  cavities  sepa- 

*  Professor  Randolph  Winslow,  of  the  University  of  Maryland,  executed  a  gastro- 
plication  upon  a  well-known  physician  of  Baltimore  upon  my  advice.  The  patient  was 
over  sixty  years  of  age,  made  a  perfect  recovery,  and  was  well  at  date  of  revision,  four 
months  after  operation.  There  had  been  motor  insufficiency  for  five  years  and  loss  of 
secretion  due  to  constant  drain  upon  the  secretory  apparatus.     The  secretion  of  HCl  was 

found  to  be  equal  to  20°       NaOH  four  months  after  operation. 


FACTORS   INFlvUENCING   OPERATIVE   MORTALITY.  367 

rated  by  a  narrow  isthmus.  Von  Hacker  reports  and  pictures  cases 
of  hour-glass  stomachs  compHcated  with  cicatricial  pyloric  stenosis, 
for  which  he  recommends  a  double  operation— either  a  pylorectomy, 
or  a  pyloroplastic  operation  with  gastro-anastomosis,  or,  best,  a 
gastro-enterostomy  and  gastro-anastomosis  (von  Hacker,  "Magen- 
operationen,"  Wien,  1895). 

The  Fundamental  Factors  Influencing  the  Rate  of  Mortality 
in  Gastric  Operations.— These  are  partly  under  the  control  of  the 
surgeon  and  partly  not.  Those  over  which  we  may  exercise  control 
are  (I)  defects  in  the  technic,  (II)  selection  of  the  kind  of  operation, 
(III)  duration  of  the  operation. 

The  factors  that  escape  control  are  (I)  age  of  the  fundamental  dis- 
ease, (II)  nature  and  extent  of  this  disease,  (III)  age  of  the  patient. 

A.  Factors  under  the  Control  of  the  Surgeon. 

I.  Faults  in  the  technic,  as  a  rule,  lead  to  peritonitis,  of  which  one 
must  distinguish  two  kinds:  (a)  The  septic,  produced  by  infection 
during  the  operation ;  and  (6)  perforation  peritonitis,  due  to  a  tech- 
nical defect  in  placing  the  sutures.  Perforation  peritonitis  as  a  result 
of  insufficiency  of  the  sutures  is  much  more  common  in  pylorectomy 
than  in  gastro-enterostomy,  because  the  lines  of  suture  are  much 
longer.  However,  peritonitis  may  be  caused  by  errors  in  diet  or  by 
spontaneous  perforations  in  other  parts  of  the  stomach,  independ- 
ently of  the  technic.  In  165  fatal  cases  with  autopsies,  the  cause  of 
death  was  peritonitis  in  one-fourth  of  the  cases;  only  three  fatal 
cases  were  due  to  spontaneous  peritonitis. 

II.  the  selection  of  the  proper  operation  for  any  particular  case  is 
facilitated  by  an  exact  definition  of  the  indications. 

The  indications  for  pylorectomy  are:  (i)  the  operable  carcinoma 
or  sarcoma ;  (2)  the  peptic  stenosing  ulcer  or  cicatrix ;  (3)  perforation 
from  pyloric  ulcer. 

The  contraindications  are : 

(i)  (a)  Firm  adhesions,  especially  posteriorly  on  account  of  danger 
of  injuring  the  hepatic  artery  and  vein ;  (6)  adhesions  with  the  pan- 
creas, (c)  with  the  liver,  {d)  with  the  meso-  and  transverse  colon. 

(2)  Infiltration  of  lymphatic  glands  (a)  of  the  lesser  omentum,  (6) 
posterior  surface  of  the  stomach,  (c)  of  the  porta  hepatis. 

(3)  Icterus  from  metastases  or  compression  by  the  tumor. 

(4)  Great  exhaustion  of  the  patient. 

Severe  gastric  hemorrhage  can  be  treated  in  most  cases  by  internal 
medication.     Gastric  ulcers  that  have  given  rise  to  repeated  grave 


368         SURGICAL   TREATMENT   O^   ORGANIC    GASTRIC   DISEASES. 

hemorrhages  have  been  successfully  excised  by  Czerny  ("Archiv  f. 
klin.  Chir.,"  1884),  Cordua  (quoted  in  Debove  and  Remond,  "Traite 
de  Mai.  de  rEstomac"),  and  Mikulicz  ("Deutsche  med.  Wochen- 
schr.,"  1892). 

Dunin  asserts  that  ulcers  in  the  pyloric  region  causing  serious  hem- 
orrhages would  heal  rapidly  if  the  pyloric  passage  were  put  at  rest  by 
a  gastro-enterostomy  (Mintz,  loc.  cit.). 

Kiister  cured  persistent  hematemesis  from  pyloric  ulcer  on  the  pos- 
terior wall  by  opening  the  anterior  wall,  producing  scabbing  incrusta- 
tion with  the  thermocautery,  and  making  a  wide  gastro-enterostomy. 
During  the  operation  a  cherry-stone  was  extracted  from  the  depth  of 
the  ulcer.  Mikulicz  did  a  pyloroplastic  operation  for  uncontrollable 
hemorrhage.  The  gastro-enterostomy,  after  cicatrizing  the  ulcers 
with  the  thermocautery,  is  generally  a  prophylactic  measure  to  fore- 
stall a  prospective  pyloric  stenosis.  A  pyloroplastic  operation  may 
accomplish  the  same  object. 

For  perforation  of  gastric  ulcer  many  operations  have  been  exe- 
cuted. Pariser  has  recently  reported  forty- three  such  operations, 
with  thirty-three  deaths  and  ten  recoveries.  Only  in  four  cases  was 
the  perforation  in  the  pylorus  (Pariser,  "Deutsche  med.  Wochen- 
schr.,"  1895).  N.  Senn  suggested  gastric  distention  with  hydrogen, 
in  order  to  rapidly  find  out  the  seat  of  the  perforation. 

Indications  for  gastro-enterostomy : 

(i)  Pyloric  carcinoma  with  extensive  adhesions  and  glandular 
metastases.  Frequently  it  is  not  decided  to  do  a  gastro-enterostomy 
until  the  abdomen  is  opened ;  a  resection  has  often  been  planned,  but 
had  to  be  replaced  by  a  gastro-enterostomy.  If  the  posterior  wall 
alone  is  free  from  infiltration,  von  Hacker's  method  is  indicated;  in 
the  reverse  case,  the  methods  of  Wolfler  or  Billroth-Brenner. 

(2)  Stenosing  ulcer  (a),  both  when  the  pylorus  is  still  isolated  and 
free,  and  (h)  when  it  is  adherent  to  its  surroundings.  With  this  indi- 
cation pylorectomy  is  unjustifiable,  but  partial  resection  and  pyloro- 
plastic surgery  may  yet  compete  with  gastro-enterostomy.  When, 
however,  a  cicatricial  pyloric  stenosis  extends  into  the  duodenum, 
nothing  but  a  gastro-enterostomy  should  be  done. 

(3)  Stenoses  in  the  duodenum  outside  of  the  pylorus.  Four  opera- 
tions, with  3  recoveries,  have  so  far  been  executed  for  this  indication. 

(4)  Stenoses  by  neoplasms  of  neighboring  organs — the  gall-bladder, 
periportal  lymphatic  glands,  and  pancreas.  Novarro  performed  a 
gastro-enterostomy  ("Deutsche  med.  Wochenschr.,"   1891,   No.  4, 


THE   MURPHY   BUTTON    AND    SENN'S    BONE-PLATES.  3^9 

S.  152).  Stansfield  did  the  same  operation,  with  good  result,  for 
tumor  of  the  pancreas  ("Brit.  Med.  Jour.,"  1890,  pp.  294  and  1300), 
making  use  of  Senn's  bone-plates. 

(5)  Purely  functional  dilatation  due  to  atony  of  the  musculature 
without  pyloric  stricture.  Four  gastro-enterostomies  for  this  indica- 
tion are  on  record.  GastropHcation  (resection  or  reduplication  of  a 
fold  of  the  stomach-wall)  is  preferable  for  this  purpose. 

III.  The  Duration  of  Gastric  Operations.— It  is  evident  that  the 
sooner  an  operation  is  completed,  the  less  the  danger  of  shock  and  sep- 
sis. With  the  view  of  shortening  the  time  of  operation,  Rydygier  and 
Lauenstein  advised  the  employment  of  continued  sutures,  which  they 
claim  abbreviate  the  time  by  one  hour.  The  most  celebrated  time- 
and  labor-saving  devices  in  gastro-intestinal  surgery  are  by  our  coun- 
trymen, Murphy  and  Senn.  The  advocates  of  Senn's  bone-plates 
have  claimed  that  the  mortality  under  the  older  suture  methods  was 
from  42.8  per  cent,  to  47  per  cent.  (Herbert  Page  and  von  Hacker), 
and  in  forty-one  operations  by  the  vSenn  method  the  mortality  was 
only  24.5  per  cent. 

The  decalcified  bone-plates  of  vSenn  are  not  always  digested.  In 
one  of  the  inventor's  own  cases  they  were  vomited  undigested  forty 
hours  after  the  operation.  Haberkant  asserts  that  the  advantage  of 
the  saving  of  time  is  counterbalanced  by  less  safety.  For  surgical 
opinions  on  the  Murphy  button  and  Senn  plates  we  must  refer  to 
journals  and  text-books  on  abdominal  surgery.  But  so  much  is 
clear :  shortening  of  the  time  of  operations  by  these  contrivances  is  a 
great  gain. 

B.  Factors  that  Escape  Control. 

I.  Age  of  the  Underlying  Disease.— This  can  not  be  determined 
statistically,  for  both  ulcer  and  carcinoma  may  remain  latent  for 
months,  and  it  is  impossible  to  ascertain  the  age  of  these  conditions  at 
the  autopsy.  We  have  observed  a  large  carcinoma  in  a  white  woman 
who  died  at  Bay  View  Hospital.  The  neoplasm  occupied  the  poste- 
rior gastric  wall;  during  life  there  had  been  no  gastric  symptoms 
whatever.  Osier's  case  of  very  rapid  course  in  gastric  carcinoma- 
two  weeks  from  the  onset  of  severe  dyspeptic  symptoms— made  it 
plain  at  the  autopsy  that  the  growth  had  been  of  considerable  dura- 
tion, but  had  for  a  long  time  not  undermined  the  patient's  health 
("Univ.  Medical  Magazine,"  January,  1895).  The  anamnesis  given 
by  patients  regarding  the  period  since  when  they  have  suffered  from 
dyspepsia  is  frequently  unreliable. 


370         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

II.  Nature  and  Extent  of  the  Fundamental  Gastric  Disease. — Con- 
cerning this  point  the  statistics  show  that  the  mortahty  in  pylorec- 
tomy,  as  well  as  in  gastro-enterostomy,  is  greater  for  carcinoma  than 
for  nicer.  Under  the  head  of  contraindications  to  these  operations 
we  have  dwelt  upon  the  dangerous  influences  of  the  extent  of  the 
disease. 

III.  Effect  of  the  Age  of  the  Patient. — In  the  cases  as  they  are  pre- 
sented for  operation  there  are  so  many  other  governing  factors  that 
the  matter  of  age  does  not  appear,  from  statistics,  to  exert  much  in- 
fluence on  the  result  of  these  operations,  provided  the  other  conditions 
previously  mentioned  are  favorable.  A  difference  becomes  notice- 
able when  the  age  is  over  sixty  years.  Among  176  resections,  the 
percentage  of  mortahty  of  those  under  fifty  years  was  50.4  per  cent., 
and  those  over  fifty  years,  52.9  per  cent.  With  gastro-enterostomy 
the  rate  was  42.4  per  cent,  for  those  under  fifty  years,  and  57.7  per 
cent,  for  those  over  fifty.  These  statistics,  therefore,  do  not  confirm 
a  marked  influence  of  age  on  the  rate  of  mortality. 

A  critical  consideration  of  these  factors,  in  connection  with  other 
elements  before  mentioned,  justifies  the  hope  that  diagnosis  and  gas- 
tric surgery  have  not  reached  the  highest  development  as  yet,  and 
we  may  expect  a  further  lowering  of  the  rate  of  mortality. 

An  artificial  communication  between  the  stomach  and  intes- 
tines, as  is  performed  in  gastro-enterostomy,  may  become  much 
smaller  by  cicatricial  contraction.  Kocher  has  reported  two  such 
observations.  In  one  case  Czerny  made  an  opening  three  cm.  in 
diameter ;  at  the  autopsy,  five  months  later,  it  had  contracted  down 
to  eight  mm. 

Heinsheimer  has  made  careful  analytical  observations  on  the  meta- 
bolism in  two  cases  of  gastro-enterostomy  ("Mittheilungen  a.  d. 
Grenzgebieten  d.  Medizin  u.  Chirurg,"  Bd.  i,  S.  350).  In  this  piece 
of  work,  which  was  done  under  von  Noorden,  Rachford's  observation 
that  fats  require  a  very  thorough  and  intense  mixture  with  the  secre- 
tions of  the  pancreas  and  liver  for  their  digestion  ("Centralbl.  f. 
Phys.,"  1896,  Heft  4)  was  confirmed.  The  further  away  the  gastro- 
intestinal communication  is  laid  from  the  duodenal  orifices  of  these 
glands,  the  more  defective  the  fat  digestion  and  resorption.  It  is 
therefore  suggested  that  in  gastro-enterostomies  a  jejunal  loop,  as 
near  as  possible  to  the  duodenum,  be  anastomosed  with  the  stomach. 

For  benign  stenoses  of  the  pylorus,  pylorectomy  is  more  and  more 
deserted  in  favor  of  gastro-enterostomy,  which  gives  the  same  func- 


OPERATIVE   STATISTICS. 


tional  results  without  the  dangers   (Ernst  Siegel, 
Grenzgebieten  d.  Medizin  u.  Chir.,"  Bd.  i,  S.  347). 


371 
'Mittheil.  a  .d. 


DURATION  OF  LIFE  AFTER  RESECTION  IN  51  CASES  OF  CARCINOMA 
OF  'PY'LOR\]'S,.—{Haberkant.) 


Death. 

0 

2 

Causes  of  Death. 

Living  at  Date 
OF  THIS  Report. 

0 
n  « 

to 

After  1%  months. 

I 

Return  of  cancer. 

After  2  months, 

I 

2           " 

,3 

One  of  metastasis  in  the 

"     3 

I 

2%       " 

I 

liver. 
Acute  lung  disease,  no  re- 
turn and  no  metastasis. 

"     3K    '' 
"     4 

"     6 

I 
I 
I 

4 

2 

Return. 

"     7>^    " 

I 

5 

2 

One  of  lobular  pneumonia, 

"     8 

I 

6 

2 

one  of  chronic  pyemia. 
One    of    return,    one    of 

"     9 

'*     I  year. 

I 
2 

(>V2           " 

I 

cicatricial  stenosis. 
Return. 

"      I  year  and 
2  months. 

I 

7 
8 

2 
I 

Return. 

"     l^  years, 
"2           •' 

I 
2 

10        " 
11^    " 

I 

I 

Return. 

Rectal  and  pelvic  carci- 

"    2  years  and 
2  months, 

2 

I  year,   .    . 
13  months, 
IX  years, 

3 

2 

I 

noma. 
Two  return. 
Return. 
Return. 

"     2)4  years, 
"     almost    3 

years , 
"     Zyi  years, 

I 

I 
I 

3 

SX       " 

Total,      .    . 

I 
I 
I 

Cicatricial  stenosis. 
Not  stated  (Billroth). 

"     5  years  and 
4  months. 
Over  8  years. 

Total,  .    .    . 

I 
I 

Kocher. 
Ratimmow. 

26 

21 

RECOVERIES   AND    DEATHS:    PERCENTAGE    OF    MORTALITY    IN   379 
CASES  OF  RESECTION  OF  PYLORUS.— (v^rt-^-jrirtwA) 


0 

Ul.CER 

Q 

Result 

Carci- 

AND 

Cica- 

Sar- 
coma 

NoIndi- 
cation 

Stated. 

Year 

H 

Steno- 

Myoma. 

OF 

Opera- 

Name of 
Operator. 

w 

0 

SIS. 

Remarks. 

tion. 

■d 

13 

'O 

•d 

-d 

U 

u 

"O 

T3 

u< 

-c 

(U 

T3 

m 

> 

OJ 

> 

III 

> 

> 

> 

S 

D 

0 
0 

0 

0 
0 

Q 

0 
u 

Q 

0 
0 

Q 

0 
u 

Q 

11 

V 

<i 

oi 

Oi 

2 

2 

— 

OS 

Pi 

1885 

Rydygier,     . 

,s 

3 

2 

I 

1885 

Gussenbauer, 

6 

2 

4 

4 

2 

1889 

Angerer,  .    . 

6 

I 

S 

I 

S 

1890 

Bilhoth,    .    . 

41 

iq 

22 

12 

16 

6 

6 

I 

Of  these,   thirty-six 

Sar- 

were   total    resec- 

coma, 

tions;  three  partial, 
two  atypical  pylo- 

. 

rectoitiies. 

372 


SURGICAL   TREATMENT   OF    ORGANIC   GASTRIC   DISEASES. 


Recoveries  and  Deaths  :    Percentage  of  Mortality  in  379  Cases  of 
Resection  of  Pylorus. — {Habe?-kant.) — [Continued.) 


Year 

OF 

Opera- 
tion. 


1890 
1890 
189I 
1892 
1892 
1893 


1893 

1893 
1893 
1893 


1895 


Name  of 
Operator. 


Lauenstein, . 
Novarro,  .  . 
Tillmans, 
V.  Heinecke, 
Schonborn,  . 
Roux,   .    .    , 


Doyen, 

Lobker,  . 
Schede,  . 
von  Kleef, 
Kraske,  . 
Czerny,     . 


Kocher, 


Kronlein, 
Kappeler, 


Mikulicz,      . 

Other  cases, 
exclusive  of 
above,    .    . 


Total, 


14 


166 


379 


Result. 


15 


79 


191 


87 


Carci- 
noma. 


13 


60 


130 


76 


145 


Ulcer 

AND 

Cica- 
tricial 
Steno- 
sis. 


32 


Sar- 
coma 

AND 

Myoma. 


2 

Sar- 


No  Indi- 
cation 
Stated. 


24 


One  atypical,  the 
rest  typical,  total 
resections. 

All  atypical  pylorec- 
tomies. 


Three  partial  resec- 
tions, the  rest  typ- 
ical, total  pylorec- 
tomies. 

In  all  nine  cases 
Kocher  used  his 
method  with  fol- 
lowing gastroduo- 
denostomy. 

Total  mortality,  35.7 
per  cent.  For  car- 
cinoma alone,  38.1 
per  cent. 


Of  these,  147  were 
total  resections ; 
17  atypical,  and  2 
partial  pylorecto- 
mies. 


23 


RESULTS  WITH  GASTRO-ENTEROSTOMY  FROM  1885  TO  1893. 


4: 

< 

> 
h 

Ulcer  and 

0 

iii 

Result. 

Ca 

rcinoma. 

Cicatricial 

0. 

0   . 

<  f- 
h  Z 

Stenosis. 

Author. 

Oo 
K 

-a 

V 

•a 

(L> 

•0 

>!._; 

<u 

■6 

-£"■"■ 

OS 

a 

> 

<cu 

>       a 

5  S 

>• 

D 

0 

Q 

h 
0 
H 

0 

Q 

0  £ 

0 

Pi 

Q 

5fe 

1885 

Kramer,     .... 

20 

8 

12 

S 

II 

68.7 

3 

I 

1886 

Saltzmann, 
Rock  wit  z, 

23 
2Q 

6 
II 

12 
12 

66.6 

'5 

1887 

16 

13 

44.8 

I 

1890 

Novarro,  . 

ss 

.    . 

24 

43-6 

.       , 

1890 

Mehler,     . 

55-1 

, 

S8  8 

.    . 

38.5 

189I 

Page,     .    . 

36 

.    . 

15 

41.6 

.       , 

1892 

Hadra,  .    . 

76 

33 
86 

43 
66 

56 
43-4 

1893 

Zeller,    .    . 

152 

391 

24 

64 

141 

144 

8 

2 

RESULTS  OF  VARIOUS   OPERATORS  WITH.  GASTRO-ENTEROSTOMY. 


•4 

u 
n 

Operator. 

a 

(U 

0. 

0 

M  Z 

5  0 
<S: 

u.  Q 
0  w 

w  ^ 

n 

S 

D 

z 

Carci- 
noma. 

Ulcer 

AND 

Cica- 
tricial 
Sten- 
osis. 

Dilata- 
tion 

OF  THE 

Stom- 
ach. 

Sar- 
coma. 

No  Indi- 
cation 
Stated. 

Remarks. 

0  ^ 

Bi 
•< 

III 
>< 

ii 

u 

V 

> 

0 
0 

OJ 

Oi 

T3 
01 

5 

■V 
V 

> 

0 

u 

lU 

•d 
u 

(5 

•6 

V 

> 
0 
u 

0) 
Oi 

6 

■d 

<u 

> 

0 
1) 
OS 

V 

■q 

•d 

> 

0 
0 

01 

■d 

5 

1887 
1890 
1890 
1891 
I89I 
I89I 

I89I 

I89I 
1893 
1893 

1893 
1893 

1893 
1893 

1894 
1894 

Liicke,      .    . 
Billroth,   .    . 
Novarro,  .    . 
Lauenstein,  . 
Hahn,  .    .    . 
Bowreman    - 
Jesset,    .    . 
Senn,    .    .    . 

Remedi,  .    . 
Roux,   .    .    , 
Doyen,     .    . 

von  Kleef,   . 
Cordivilla,    . 

V.  Heinecke, 
Lobker,    .    . 

Czerny,     .    . 
Kraske,    .    . 
Other  cases, 
exclusive  of 
'   above,    .    . 

Total,    .    . 

8 
28 
10 

17 
II 

5 
13 

6 

14 
10 

19 
6 

6 

7 

23 
10 

.95 

388 

5 
14 

5 
10 

'7 

2 

4 
4 

12 

7 

66 
136 

I 

14 
3 
3 

3 

7 

2 
3 

7 
3 

59 
105 

2 

2 
2 

3 

4 

2 

20 
35 

2 

. 
I 

9 
12 

I 

2 
3 

■ 

I 
I 

I 

I 

I 

5 

3 
4 

6 
13 

21 

52 

6 

2 
9 

4 
5 

16 
42 

Calculated  according 
to  Czerny. 

Two    carcinomata, 
eight  cicatrices. 

Operated  in  one  year 
by    von    Hacker's 
method. 

All  according  to  von 
Hacker's  method. 

373 


374         SURGICAIv   TREATMENT   OF    ORGANIC    GASTRIC    DISEASES. 
DURATION  OF  LIFE  AFTER  GASTRO-ENTEROSTOMY. 


After  I  month 

"  Ij^  months, 

"  2 

"  3 

"  zY^ 

■  "  4 

"  6 

"  lo 

"  I  year, 

"  I  year  and  2  months, 

"  1)4.  years, 

"  I  year  and  7  months, 

"  I     "      "8        " 

"  I      "        "  lO         " 


Total, 


Number 

OF 

Cases. 


42 


Living  and  at  the  Time  of 
Report  in  Good  Health. 


Number 

OF 

Cases. 


After  2  months. 


4 
5 
6 

7 

9 
lo 

1  year  and  1 1  months, 

2  years, 


Total, 


I  (Hahn). 


i6 


EFFECT    OF   AGE   ON    THE    RESULT   OF    VARIOUS    GASTRIC    OPERA- 
TIC N  S .—( i% -5^r/§a«/. ) 


Total  Typical 

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Atypical  Resec- 

Pyloroplastic 

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tomy. 

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Operation. 

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(71) 

(73) 

GASTRIC    DISEASES    AND    GENERAL   NUTRITION.  375 


CHAPTER  VIII. 

INFLUENCE  OF  GASTRIC  DISEASES  UPON  OTHER 
ORGANS  AND  ON  METABOLISM. 

Diseases  of  the  stomach  may,  as  is  well  known,  affect  general  nutri- 
tion, the  action  of  the  heart,  lungs,  and  the  nervous  s^^stem. 

In  all  digestive  diseases  with  apparent  malnutrition  the  physician 
should  ascertain  the  amount  and  the  kind  of  food  ingested,  the  state 
of  the  stool,  and  sleep.  The  cause  of  insufficient  ingestion  of  food  is 
anorexia  in  the  majority  of  cases ;  in  others  the  patients  have  a  good 
appetite,  but  avoid  food  because  it  gives  them  pain,  as  in  the  case  of 
gastric  ulcer ;  others,  again,  will  not  eat  because  they  vomit  the  food 
soon  after  ingestion.  Toss  of  weight  is  of  more  serious  significance 
in  chronic  than  in  acute  stomach  diseases.  Instead  of  taking  in 
thirty  to  forty  calories  per  kilogram  of  body  weight,  von  Noorden 
found  in  chronic  types,  after  careful  observation,  that  they  ingested 
only  twenty-one  calories  of  their  own  accord  (v.  Noorden,  "Ueber 
Stoffwechsel  d.  Magenkranken, "  etc.,  "Berhner  Klinik,"  Heft  55). 
In  cases  in  which  the  HCl  secretion  was  so  diminished  that  only  a 
fraction  of  the  proteids  could  be  peptonized  in  the  stomach  and  the 
largest  portion  passed  into  the  intestines  unchanged,  von  Noorden 
found  that  resorption  of  the  main  food-substances  was  sufficient. 
With  a  good  gastric  peristalsis,  preventing  delay  and  fermentation  in 
the  stomach,  the  intestine  is  capable  of  supplanting  the  deficient  gas- 
tric digestion.  In  animals,  total  exclusion  of  the  stomach  from  the 
digestive  act  need  not  injure  general  nutrition,  provided  the  food  is 
supplied  in  a  proper  form. 

It  is  very  probable  that  in  certain  forms  of  gastritis,  in  ectasias  and 
carcinoma,  poisonous  substances  are  formed  which  are  resorbed  and 
injure  the  metabolism  of  the  tissues.  Friedenwald  has  recently 
found  this  to  be  the  case  in  atony  of  the  intestines  and  stomach 
("Med.  News,"  Dec.  23,  1893). 

Resorbable  and  combustible  gases  are  developed  in  gastrectasias 
with  stagnating  ingesta  and  have  been  described  by  many  observers 
(see  Albu,  "Die  Autointoxicationen  des  Intestinaltractus,"  p.  19). 
Putrefaction  of  albuminous  substances  may  occur  in  the  stomach. 
Some  cases  show  the  formation  of  sulphuretted  hydrogen  even  with 
25 


376      INFLUENCE    OF    GASTRIC    DISEASES    UPON    OTHER    ORGANS. 

co-existent  high  acidity.  Naturally,  stagnation  must  be  present  to 
make  albuminous  decomposition  possible.  Miiller  has  described  a 
series  of  carcinoma  cases  in  which  more  nitrogen  was  excreted  than 
ingested  in  the  food  ("Zeitschr.  f.  klin.  Med.,"  Bd.  xvi),  which 
strengthens  the  conception  of  carcinomatous  auto-intoxication,  caus- 
ing an  increased  albuminous  breakdown  in  the  tissues. 

In  all  cases  of  subnormal  nutrition  all  etiological  factors  must  be 
sought  out,  and  an  individualized,  highly  nutritious,  concentrated, 
unirritating  diet  adapted  to  the  patient  after  improving  the  appetite.* 

Influence  of  Gastric  Diseases  on  the  Heart. — It  is  natural  to 
expect  increased  rapidity  of  the  heart's  action  in  all  gastric  diseases 
associated  with  fever,  such  as  the  various  forms  of  acute  gastritis,  in 
perigastritis,  and  other  complications  (peritonitis) .  But  tachycardia 
has  frequently  been  observed  by  us  associated  with  hyperacidity, 
gastrosuccorrhea,  and  pneumatosis.  In  one  case  of  the  latter  disease 
the  tachycardia  was  so  persistent  as  to  require  special  treatment  by 
local  ice-bag,  aconite,  and  bromid  of  strontium.  In  all  of  these  cases 
fever  was  absent,  and  we  have  no  experimental  basis  to  explain  the 
phenomenon. 

Bradycardia  is  seen  much  more  frequently,  and  the  fact  that  it  is 
aggravated  and  improves  or  disappears  as  the  gastric  trouble  be- 
comes worse  or  better,  shows  that  it  is  not  an  accidental  accompa- 
niment, but  is  in  some  causal  relation  with  the  fundamental  disease 
— i.  e.,  dilatation  or  ulcer.  In  animals,  slowing  of  the  pulse  can  be  ef- 
fected by  distention  or  rough  manipulation  of  the  stomach.  Stimu- 
lation of  sensory  nerves  causes  slowing  of  the  heart-beat,  and  this 
may  partly  be  offered  as  an  explanation  of  bradycardia  in  dilatation 
and  ulcer,  though  it  is  far  from  satisfactory.  It  is  difficult  to  prove 
that  irregular  heart's  action  or  arrhythmia  is  dependent  upon  gastric 
diseases,  even  when  it  actually  is  associated  with  the  latter.  Arrhyth- 
mia is  so  frequent  that  it  may  accidentally  be  present  in  an  individual 
independently  of  any  gastric  disease. 

Patients  with  weak  hearts,  valvular  disease,  failure  of  compensa- 
tion, should  be  carefully  dieted,  and,  if  in  extreme  dyspnea,  should 
not  be  allowed  anything  but  milk  until  this  symptom  is  relieved. 
Arrhythmia  and  compensatory  defects  are  more  pronounced  after 
full  meals.     The  relation  is  not  perfectly  clear ;  but  we  have  observed 

*  The  literature  on  the  correlation  of  digestive  diseases  and  those  of  other  organs,  and 
vice  versa,  will  be  found  in  Dr.  Hans  Herz's  "  Storungen  des  Verdauungsapparates  als 
Ursache  u.  Folge  anderer  Erkrankungen,"  Berlin,  1898. 


INFLUENCE  OF  GASTRIC  DISEASES  ON  NERVOUS  SYSTEM.         377 

a  number  of  deaths  in  patients  suffering  from  organic  cardiac  disease, 
following  shortly  after  a  full  meal  that  was  apparently  enjoA'ed. 
These  deaths  may  be  attributed  to  a  number  of  causes — viz.:  (i) 
Impediment  offered  to  excursions  of  the  diaphragm  by  the  full  stom- 
ach; (2)  pressure  on  the  weak  heart,  and  irritation  of  the  pneumo- 
gastric  nerve,  due  to  distention  of  the  stomach  by  gases;  (3)  absorp- 
tion of  toxins  from  improperly  digested  food ;  (4)  increased  intracar- 
diac pressure  occurring  naturally  during  gastric  digestion.  When 
the  heart  is  dilated  or  hypertrophied,  very  small  meals  only  should 
be  permitted. 

Palpitation  of  the  heart  occurs  in  many  persons,  particularly  after 
heavy  meals ;  the  pulse  becomes  faster,  fuller ;  the  tension  greater — 
all  this  with  intact  hearts,  but  particularly  observable  in  the  course  of 
chronic  gastric  diseases,  dilatations,  abdominal  plethora,  and  con- 
stipation. 

Respiration. — It  is  undoubted  that  breathing  is  influenced  by 
gastric  troubles,  although  sufficient  attention  has  not  been  given  to 
this  matter.  We  have  noticed  in  a  number  of  cases  that  the  respira- 
tory expansion  is  lessened  by  gastric  diseases  impeding  the  excur- 
sions of  the  diaphragm.  This  we  have  produced  experimentally  in 
healthy  individuals  by  inflating  our  stomach-shaped  intragastric 
rubber  bag  within  their  stomach  while  they  were  under  narcosis. 

It  appears,  therefore,  that  undue  or  excessive  gastric  distention 
diminishes  the  amount  of  inspired  air,  independently  of  conscious- 
ness. In  gastric  fermentations  toxic  substances  are  produced,  which, 
when  injected  into  the  circulation,  caused  dyspneic  respiration  of  a 
paroxysmal  character  (Bouchard  and  Bouveret).  It  is  probable, 
therefore,  that  gastric  diseases  may  affect  respiration  either  directly 
or  mechanically,  through  interference  with  the  descent  of  the  dia- 
phragm or  by  the  absorption  of  toxins  and  action  on  the  respirator}' 
center.  With  the  intimate,  mutual  correlation  of  the  physiology  of 
the  circulatory  and  respiratory  function,  it  is  evident  that  a  patho- 
logical disturbance  of  one  will  inevitably  affect  the  other. 

The  Influence  of  Gastric  Diseases  on  the  Nervous  System. — 
Nervous  patients  affected  with  a  disease  of  the  stomach  frequently 
exhibit  neuroses  of  sensation:  hyperesthesia,  intercostal  neuralgias, 
and  hemicrania.  That  there  is  some  etiological  connection  between 
the  stomach  and  these  conditions  is  made  very  probable  by  the  fact 
that  very  frequently  they  only  occur  after  full  meals  (dinner),  or,  if 
they  existed  before,  they  are  aggravated  by  copious  eating,  and  be- 


378      INFLUENCE    OF    GASTRIC    DISEASES    UPON   OTHER   ORGANS. 

come  ameliorated  or  disappear  as  digestion  is  completed.  The  pains 
often  return  toward  night  and  on  going  to  bed,  causing  insomnia. 
Patients  that  are  experienced  in  the  use  of  the  stomach-tube  are  able 
to  arrest  these  pains  at  times  by  lavage.  Occasionally,  the  colon  is 
the  cause  of  the  pain  irradiation ;  this  is  especially  to  be  looked  for  in 
membranous  colitis  or  compression  of  the  colon  from  tight  lacing,  or 
in  the  various  forms  of  enteroptosis. 

Gastric  vertigo  is  a  form  of  dizziness  or  partial  unconsciousness 
without  pain,  but  frequently  with  nausea  and  vomiting,  occurring  in 
gastric  sufferers.  Trousseau,  who  gave  a  classical  description  of  this 
affection,  argued  that  one  of  its  peculiarities  was  that  consciousness 
remained  clear  during  the  attack  (Trousseau,  "Clin,  de  I'Hotel  Dieu," 
Paris,  tome  iii,  1868).  Teube  and  Trousseau  were  of  the  opinion 
that  it  occurred  most  frequently  with  chronic  gastritis.  Boas  and 
Herz  consider  that  myasthenia  is  the  most  frequent  substratum. 

We  have  observed  transient  loss  of  consciousness  which  at  times 
developed  from  typical  stomach  vertigo.  This  affection  occurs,  in 
our  experience,  in  neuropathic  patients  with  hyperacidity,  particu- 
larly when  the  stomach  is  empty,  and  is  associated  more  often  with 
this  gastric  neurosis  than  others. 

It  is  a  more  frequent  complication  of  hyperchylia  than  is  generally 
known,  since  many  patients  will  not  speak  of  their  transient  attacks 
unless  especially  questioned.  Emesis  often  checks  the  attack,  and 
Trousseau  mentions  that  a  cup  of  bouillon  or  a  cake  soaked  in  wine 
may  check  the  vertigo. 

Treatment  of  the  fundamental  gastric  disease  removes  the  vertigo, 
as  a  rule,  but  in  explanation  of  the  way  in  which  the  vertigo  is  caused, 
its  nervous  mechanism,  etc.,  we  have  nothing  but  hypotheses. 

Symptoms. — The  symptoms  accompanying  gastric  vertigo  are 
nausea,  eructation,  pyrosis,  vomiting,  sensitiveness  in  the  epigastric 
region,  pain  in  the  stomach,  and  a  feeling  of  pressure,  fullness,  and  dis- 
tention. In  the  majority  of  cases  constipation  exists,  and  the  abdo- 
men is  frequently  distended  with  gases.  In  some  few  cases  a  dilatation 
was  found  to  be  present.  Vertigo  has  been  observed  to  occur  almost 
at  any  stage  of  digestion — before,  during,  and  after  meals.  Some- 
times the  attacks  of  giddiness  are  announced  by  a  sensation  of  great 
hunger  or  bulimia.  Teube  mentions  that  gastric  vertigo  ma)^  occur 
in  some  persons  after  the  ingestion  of  certain  foods.  It  may  occur 
either  at  intervals  of  several  days  or  several  times  in  the  same  day. 
It  is  generally  a  chronic  and  permanent  trouble,  but  in  its  lighter 


GASTRIC   VERTIGO.  379 

forms  it  has  no  serious  influence  on  the  condition  of  the  patient.  The 
treatment  of  gastric  vertigo  necessitates  the  treatment  of  the  under- 
lying condition  of  the  stomach. 

Leube  has  described  an  intestinal  lertigo  associated  with  intestinal 
diseases  of  various  kinds,  but  generally  not  of  a  serious  character. 
The  most  frequent  causes  are  constipation  and  intestinal  parasites, 
mainly  lumbricoid  and  tape-worms.  These  attacks  of  gastric  vertigo 
are  as  yet  not  satisfactorily  explained.  Leube  has  in  some  cases  been 
able  to  produce  the  attack  by  pressure  on  the  stomach  or  intestines 
(Leube,  "Ueber  den  Magenschwindel"  ;  Ziemssen's  "Handb.  d.  spec. 
Path.  u.  Ther.,"  vol.  11,  p.  66).  Mayer  and  Pribram  claim  to  have 
observed  excitation  of  the  vasomotor  center  after  irritation  of  the 
stomach,  particularly  of  the  serous  coat  (Mayer  and  Pribram,  "Ueber 
reflect.  Bezieh.  d.  Magens  z.  d.  Innervationscentren  f.  d.  Kreislauf- 
sorg.,"  "  Sitzungsber.  d.  Wien.  Akad.  d.  Wiss.,"  1872).  A  second 
theory  in  explanation  of  stomach  vertigo  presumes  that  it  is  caused 
by  cerebral  anemia,  or  hyperemia,  which  is  not  described  as  a  reflex 
act,  but  as  a  direct  detrimental  influence  on  the  circulation  of  the 
brain.  This  hypothesis  exaggerates  the  degrees  of  circulatory  varia- 
tion that  can  possibly  occur  in  such  light  forms  of  digestive  disturb- 
ance in  which  vertigo  is  observed.  A  third  theory  explains  gastric 
vertigo  on  the  basis  of  auto-intoxication.  It  is  presumed  that  prod- 
ucts of  abnormal  digestion,  which  collect  when  the  motor  function 
of  the  stomach  and  intestines  is  disturbed,  are  absorbed  into  the  cir- 
culation, and  act  directly  upon  the  brain.  There  is  an  abundance  of 
experimental  evidence,  as  well  as  clinical  experience  , which  proves 
that  such  an  effect  of  toxic  chemical  substances  is  possible.  Such 
toxic  irritation  may  be  indirect,  and  is  intermediated  through  the 
vasomotor  center.  Brieger  has  isolated  a  substance  from  dilated 
stomachs  which  he  has  termed  peptotoxin,  which  has  an  extremel}^ 
poisonous  effect  when  injected  into  the  circulation  of  animals.  In 
case  of  the  presence  of  intestinal  parasites,  the  toxic  metabolic  prod- 
ucts of  the  helminthiasis  are  added  to  those  of  disturbed  digestive 
function. 

Rosenbach  has  demonstrated  that  there  is  a  regulatory  apparatus 
for  the  body  movements  and  for  equilibrium  in  the  epigastric  region. 
This  center  distinctly  enters  into  function  when  tests  are  made  with 
eyes  closed.  This  observation,  if  confirmed,  would  permit  of  new  in- 
sight into  the  pathology  of  gastric  vertigo.  For,  if  this  abdominal 
regulatory  apparatus  receives  abnormal  impulses,  it  is  plausible  that 


380      INFLUENCE    OF    GASTRIC   DISEASES    UPON    OTHER    ORGANS. 

they  may  be  conducted  to  the  cerebrum  by  way  of  the  sympathetic 
system. 

Tetany. — The  term  signifies  characteristic  conA'ulsive  attacks 
which  occur  in  the  course  of  gastric  diseases,  particularly  in  dilata- 
tions associated  with  hypersecretion.  The  term  "tetany"  was  first 
used  in  1S52  by  Con.-isart.  The  spasms  are  prevailingly  tonic  con- 
tractions, alternating  with  less  severe  twitchings  in  the  flexor  muscles 
of  the  arms,  calves,  and  generally  also  of  the  abdominal  muscles. 
The  facial,  cerA'ical,  and  maxillary-  muscles  are  occasionalh'  attacked 
by  the  tetany,  the  e3'es  may  be  turned  upward,  and  CA'en  emprostho- 
tonos  of  short  duration  has  been  reported.  The  convulsions  mav  be 
painful  and  consciousness  may  be  clear  or  completely  obscured.  In 
one  case  of  Kussmaul's  the  power  of  speech  was  lost ;  in  another  the 
patient  spoke  disconnectedh'  and  his  pupils  did  not  react  to  light. 
In  a  third  the  symptoms  referring  to  the  cerebrum  were  absent,  but  a 
fourth  case  of  Kussmaul's  was  of  an  epileptic  form  and  character. 
Bouveret  and  Devic  ("Rech.  chn.  et  experim.  sur  la  tetanie  d'ori- 
gine  gastrique,"  "Revue  de  Medec,"  1892,  12,  p.  48)  have  collected 
twenty- three  cases  of  these  tetanic  attacks,  and  Albu  ("Autointoxi- 
cationen  des  Intestinaltractus,"  Berlin,  1895)  states  that  not  more 
than  thirty-six  cases  of  this  complication  of  gastric  diseases  have  been 
reported.  Kussmaul  gaA'e  the  first  classical  description  of  these 
attacks  in  his  famous  publication  on  the  treatment  of  gastric  dilata- 
tions by  a  new  method  b}-  means  of  the  stomach-pump  ("Deutsches 
Archivf.  khn.  Med.,"  Bd.  vi). 

CHnically.  it  is  not  correct  to  designate  all  tonic  muscular  convul- 
sions of  gastric  origin  as  tetany.  In  true  gastric  tetany  there  is  an 
increased  mechanical  excitability  of  the  muscles,  and  an  increased 
mechanical  and  electrical  irritability  of  the  motor  and  sensors'  ners'es, 
which  precede  the  attack  and  may  persist  long  after  it.  Cases  have 
been  reported  b}"  Fleiner  and  Kussmaul  which  strongly  resembled 
typical  tetanus.  Cases  are  reported  in  which  the  clinical  picture 
varied  between  tetany,  tetanus,  and  epileptiform  convulsions.  In 
most  of  the  cases  Trousseau's  phenomenon — /.  e.,  the  production  of 
spasms  by  pressure  on  the  nerve-trunk:s — was  present.  Among 
twenty-seven  cases  that  were  collected  by  Riegel,  sixteen  proved 
fatal.  According  to  this,  tetany  is  a  very  grave  complication  of  gas- 
tric diseases.  The  gastric  diseases  with  which  tetany  is  associated 
are  extensive  dilatations,  due  mostly  to  stenosis  of  the  pylorus  or 
duodenum,  by  ulcer  or  cicatrix.     In  several  cases  the  stenosis  was 


TETANY    OF    GASTRIC    ORIGIN.  38 1 

due  to  a  carcinoma  that  had  developed  from  a  cicatrix.  Bouveret 
and  Devic  attribute  great  importance  to  hypersecretion  for  the  pro- 
duction of  tetany.  This  comphcation  has,  however,  been  observed  in 
other  dilatations  in  which  there  was  no  hypersecretion.  Thus  far 
three  hypotheses  have  been  put  forward  attempting  to  explain  the 
origin  of  tetany:  (i)  That  of  Kussmaul,  according  to  which  it  is 
caused  by  desiccation  of  the  organism  in  consequence  of  copious  loss 
of  water.  (2)  The  explanation  according  to  which  tetany  is  caused  by 
a  reflex  irritation  of  the  central  and  peripheral  nerv'ous  systems,  and 
that  the  irritation  issued  from  the  central  branches  of  the  gastro- 
intestinal tract.      (3)  That  of  auto-intoxication. 

Kussmaul's  theory  rested  upon  the  apparent  analogy  between 
tetany  and  the  cramps  in  the  legs  occurring  with  Asiatic  cholera, 
which  are  believed  to  be  due  to  condensation  and  thickening  of  the 
blood  resulting  from  loss  of  water.  We  know,  however,  that  these 
cramps  occur  also  in  cholera  sicca.  The  loss  of  water,  Kussmaul 
thought,  was  brought  about  by  the  exhaustive  vomiting  which  usu- 
alty  precedes  the  attack  of  tetany,  but  cases  have  been  reported  in 
which  tetany  occurred  without  a  preliminary  attack  of  vomiting. 
In  cholera  nostras  (the  acute  gastro-enteritis  of  children),  where  the 
loss  of  water  is  verv^  great,  tetany  occurs  ver}^  rarely. 

Blazicek  described  a  case  of  gastric  tetany  in  which  the  percentage 
of  water  in  the  blood  was  not  reduced. 

The  second  theory,  that  of  the  reflex  origin,  has  been  proposed  by 
Germain  See.  The  arguments  of  Bouveret  and  Devic,  and  of  Ewald 
("Berlin,  klin.  AYochencshr.,"  1894,  No.  2),  emphasize  the  fact  that 
the  reflex  phenomena  are  based  upon  a  preliminary  chronic  intoxi- 
cation, which  increases  the  irritability  of  the  muscles  and  ner^^es. 
Tetany,  according  to  these  authors,  is,  therefore,  not  a  reflex  phe- 
nomena, any  more  than  are  the  convulsions  of  a  stn,xhninized  frog, 
which  result  from  the  slightest  cutaneous  irritation. 

Most  modern  authors  (Gerhardt,  Bouveret  and  Devic,  Albu, 
Ewald,  Heim,  Loeb,  Schlesinger,  and  Baginsky)  favor  an  explana- 
tion of  tetany  on  the  basis  of  gastro-intestinal  auto-intoxication.  It 
is  not  a  bacterial  intoxication  caused  by  metabolic  products  of  patho- 
genic bacteria  introduced  with  the  food  which  these  authors  have 
reference  to,  but  to  poisons  formed  in  the  stagnating,  fermenting  con- 
tents of  the  dilated  stomach.  Kulneff  has  extracted  toxic  products 
from  the  gastric  contents  in  carcinoma  and  dilatation,  which,  accord- 
ing to  their  chemical  structure,   were  classed  as  diamins.     These 


382       INFLUENCE    OF    GASTRIC   DISEASES    UPON    OTHER   ORGANS. 

toxins  were  extracted  by  Brieger's  method  (extraction  with  alcohol 
and  precipitation  with  mercuric  chlorid).  Bouveret  and  Devic  ex- 
tracted substances  from  the  stomachs  of  three  cases  of  tetany  with 
hyperchlorhydria  that  produced  spasms  when  injected  into  animals. 
Ewald  and  Jacobson  have  isolated  alkaloidal  bodies  from  the  urine  of 
tetany  patients,  and  Albu  isolated  the  double  platinic  and  gold  salt  of 
an  alkaloidal  substance  from  the  urine  of  a  woman  afflicted  with  tet- 
any. This  substance  was  absent  from  the  urine  when  the  patient  was 
free  from  the  attacks.  Tetany  occurs,  in  the  majority  of  cases,  only 
when  abnormal  fermentations  and  putrefactions  occur  in  the  stagna- 
ted contents  of  the  stomach  and  intestines.  This  intoxication  theory 
explains  the  nephritis  which  Loeb  has  observed  in  connection  with  tet- 
any. The  author  has  reported  3  cases  of  nephritis  which  probably  owe 
their  origin  to  auto-intoxication  (Hemmeter,  "Marjdand  Med.  Jour.," 
July  24  and  31,  and  Aug.  7,  1897).  The  subject  is  not  sufficiently 
investigated  to  permit  of  definite  conclusions  regarding  the  causation. 
Asthma  Dyspepticum. — In  1876  Henoch  described  a  clinical  phe- 
nomenon in  children,  in  which  attacks  very  similar  to  asthma  were 
associated  with  digestive  disturbances  (Henoch,  ' '  Berlin,  klin.  Woch- 
enschr.,"  1876,  No.  18),  and  in  1882  Silbermann  described  similar 
cases,  also  occurring  in  children  ("Berlin,  klin.  Wochenschr.," 
1882,  No.  23).  The  attacks  of  asthma  dyspepticum  are  characterized 
by  a  very  abrupt,  acute  onset,  after  a  very  evident  error  in  diet  or 
after  constipation  or  febrile  gastritis.  There  is  a  pronounced  dysp- 
nea, with  cyanosis,  very  small,  compressible,  and  hurried  pulse,  cold 
extremities,  collapse,  and,  generally,  no  symptoms  of  severe  gastric 
disturbance.  The  symptoms  disappear  as  suddenly  as  they  begin, 
after  an  emetic  has  taken  effect  or  spontaneous  vomiting  has  occurred. 
Striimpell  ("Specielle  Pathologie  u.  Therapie")  doubts  the  existence 
of  asthma  dyspepticum,  and  Riegel  also  ("Die  Erkrankungen  des 
Magens,"  Wien,  1896,  S.  192).  The  literature  on  this  subject  is  very 
limited,  and  many  of  the  cases  reported  do  not  impress  us  as  strictly 
belonging  to  the  clinical  picture  of  asthma  dyspepticum.  O.  Rosen- 
bach  ("Deutsche  medizin.  Wochenschr.,"  1879,  No.  42)  describes  a 
number  of  cases  which,  although  he  separates  them  from  dyspeptic 
asthma,  very  much  resemble  this  clinical  picture.  The  patient  com- 
plained of  oppression,  want  of  air,  difficulty  in  breathing,  and  a  sen- 
sation of  fear.  The  scarcity  of  reports  on  this  complication  is  ex- 
plained by  the  fact  that  the  physician  very  rarely  has  an  opportunity 
for  observing  these  cases  during  the  attack;  as  a  rule,  they  cease 


DYSPEPTIC  asthma:  383 

spontaneously  within  a  few  hours,  and  are  frequenth'  interrupted  by 
the  patients  by  mechanical  manipulations  to  facilitate  vomiting. 

It  is  well  known  that  conditions  of  more  or  less  anxious  oppression 
in  breathing  are  observed  occasionally  in  normal  indiA'iduals,  but 
more  frequently  in  those  afflicted  with  gastro-intestinal  diseases. 
The  attacks  occur  in  connection  with  the  larger  meals,  the  patients 
having  a  feeling  as  if  they  could  not  breathe  properly.  The  respira- 
tory oppression  and  distress  cease  spontaneousl}^  during  the  course 
of  digestion,  or  are  relieved  by  eructation  of  gases.  If  these  abnormal 
sensations  are  augmented,  and  when  they  occur  at  short  intervals 
and  after  moderate  ingestion  of  food,  the  condition  becomes  patho- 
logical. A  fear  of  smothering,  with  cyanosis,  cool  extremities,  greatly 
hurried  pulse,  and  dyspnea,  occurring  in  the  sequence  of  gastro-intes- 
tinal disturbances,  represent  a  clinical  picture  which  we  are  justified 
in  designating  as  asthma  dyspepticum.  Oppler  ("Allg.  med.  Cen- 
tralztg.,"  1896,  No.  71)  and  Tauterbach  ("Wien.  med.  Presse," 
1894,  No.  48)  have  each  described  one  case  of  asthma  dyspepticum 
as  a  sequence  to  gastric  atony.  The  case  of  Oppler  recovered 
under  laA^age,  diet,  massage,  electricity,  and  the  use  of  strych- 
nin and  belladonna.  The  cardinal  symptom  of  the  phenomenon  is 
the  paroxysmal  dyspnea.  It  occurs  most  frequently  among  women, 
and  especially  among  the  neurasthenic  and  h^^sterical.  Potain 
(Association  pour  I'Avancement  des  Sciences,  Montpellier,  1879) 
and  Barie  ("Revue  de  Medicine,"  1883,  tome  in,  p.  i)  have  together 
reported  thirty-two  cases  in  France,  a  number  of  which  gave 
indications  that  they  were  genuine  asthma  dyspepticum.  Boas 
("Archiv  f.  Verdauungskrankheiten, "  Bd.  ii,  S.  444)  gives  a  very  in- 
teresting report  of  eleven  cases — ten  males  and  one  female. 

Instead  of  going  into  details  concerning  the  symptomatolog}^  we 

will  describe  a  case  which  has  been  observed  by  the  author  repeatedly 

during  attacks: 

The  lady  in  question  lived  in  the  immediate  neighborhood  of  the  writer. 
Mrs.  S.,  aged  twenty-six,  has  suffered  for  years  with  symptoms  of  atony. 
Mother  living  and  healthy  ;  father  died  with  cancer  of  the  stomach.  She  has 
been  married  four  years,  but  has  no  children  ;  heart  and  lungs  normal.  The 
dyspeptic  symptoms  are  those  of  atony  and  nervous  dyspepsia  with  hyper- 
acidity. There  are  no  signs  of  enteroptosis  ;  right  kidney  is  firmly  attached  in 
its  normal  position;  no  history  of  uterine  trouble;  constipation.  Results  of 
analysis  of  test-meal:  Total  acidity,  90;  free  HCl,  50;  combined  HCl,  22;  ery- 
throdextrin  present  in  excess  ;  lactic  acid  absent.  Examination  of  the  urine 
for  toxic  products  gave  the  following  results  when  it  was  first  examined  ; 
this  was  shortly  after  an  attack,  and  was  also  followed  by  an  attack  on  the  next 


384      INFLUENCE    OF    GASTRIC    DISEASES    UPON    OTHER   ORGANS. 

day  :  Preformed  sulphates,  3.970  gm.  ;  combined  sulphates,  0.35  gm., — ratio, 
IT. I  ;  urea,  51.028  gm. ;  indigo  blue,  very  strong  reaction.  December  14,  1896. — 
On  this  date  the  patient  was  very  melancholy,  and  suffered  much  from  intes- 
tinal flatulence.  The  writer  was  called  just  as  an  attack  was  beginning,  and 
found  the  patient  on  the  sofa,  with  the  servants  rubbing  her  hands  and  feet, 
which  had  a  bluish  tint  and  were  quite  cold  to  the  touch.  She  had  thrown 
open  the  windows  on  a  cold  night  to  get  air,  and  was  grasping  for  breath  ;  the 
pulse  was  148.  The  patient  was  in  mortal  fear  of  smothering.  There  were 
marked  cardiac  oppression  and  a  very  peculiar  wheezing  sound  with  each 
breath,  and  tenderness  to  pressure  in  the  epigastric  region  ;  accentuation  of  the 
second  cardiac  sound.  A  stomach-tube  was  passed,  and  about  500  gm.  of 
highly  acid  liquid  drawn  off,  composed  mostly  of  melted  ice-cream  and  straw- 
berries. An  enema  was  given  containing  warm  claret  and  camphor,  and  hot 
bottles  were  placed  to  the  feet.  The  patient  broke  out  in  a  perspiration  within 
thirty  minutes  after  the  enema,  and  had  quite  recovered  two  hours  after  the 
attack.  This  same  patient  has  since  that  time,  which  was  a  year  ago,  been 
seen  in  two  other  attacks  very  similar  to  this  one,  both  of  them  yielding  to  the 
same  treatment.  Formerly,  she  had  one  attack  every  month,  not  in  any  con- 
nection with  the  menstrual  period,  however.  Addition  at  time  of  revision, 
September,  1899. — With  strict  observance  of  diet  and  the  use  of  alkalies  this 
patient  has  not  had  an  attack  during  the  last  fourteen  months. 

There  are  no  satisfactory  explanations  of  asthma  dyspepticum  up 
to  the  present  date.  Potain  {loc.  cit.)  beheves  in  a  reflex  irritation 
from  the  gastro-intestinal  tract,  which  causes  contraction  of  the  small 
pulmonary  vessels.  In  the  resistance  to  the  pulmonary  circulation 
which  is  thus  brought  about  the  respiratory  gaseous  exchanges  are 
interfered  with,  and  Potain,  as  w^ell  as  Barie,  claim  to  have  found 
dilatation  of  the  right  ventricle,  w4th  accentuation  of  the  second 
pulmonary  sound  during  the  attack.  A.  Frankel  (article  on 
"Asthma"  in  Eulenburg's  "Real-Enc^^clopadie,"  3.  Aufl.)  considers 
asthma  dyspepticum  a  reflex  disturbance  of  cardiac  asthma,  caused 
especially  by  a  weakness  of  the  left  ventricle,  which  then  secondarily 
causes  a  passive  congestion  in  the  pulmonary  circulation.  This  ex- 
planation concedes  the  trouble  to  be  essentially  cardiac  asthma. 
There  is  a  vers'  intimate  connection  between  disturbed  digestion 
and  cardiac  action,  which  we  have  already  dwelt  upon,  and  the  con- 
ception of  Frankel  is  not  without  foundation  in  those  cases  in  which 
the  heart's  action  is  not  perfectly  sound.  Boas  has  reported  cases  in 
which  the  attacks  were  brought  on  by  a  disturbed  gastric  digestion, 
with  bronchitis  and  emphysema. 

Abnormal  gastro-intestinal  meteorism  may  force  up  the  diaphragm 
mechanically,  and  if  there  is  any  debility  about  the  pulmonary  capil- 
laries, passive  congestion  can  not  fail  to  occur.     With  the  evacuation 


DYSPEPTIC   ASTHMA.  385 

or  escape  of  the  gas  the  attack  will  cease  entirely.  Senator  (' '  Berlin, 
klin.  Wochenschr.,"  1883,  No.  22),  G.  Lewin,  and  Albu  (loc.  cit.) 
claim  that  dyspeptic  asthma  is  caused  by  the  absorption  of  toxic 
substances  from  the  digestive  tract.  The  theory  of  auto-intoxica- 
tion has  been  criticized  by  Boas,  since  asthma  dyspepticum  is  not  met 
with  in  any  gastro-intestinal  diseases  associated  with  extensive  putre- 
faction and  fermentation;  whereas  in  those  slight  forms  of  gastric 
disease  in  which  this  asthma  really  does  occur,  there  is  very  little 
formation  of  toxic  products. 

Prognosis  is  favorable.  Boas,  Lauterbach,  and  Oppler  have  re- 
ported cures.  One  of  the  author's  cases  has  not  had  an  attack  for 
two  and  a  half  years  following  treatment. 

Treatment  is  mainly  a  prophylactic  and  dietetic  one.  The  stomach 
should  be  sparingly  treated,  the  bowels  kept  open,  and  all  food  caus- 
ing flatulence  must  be  scrupulously  avoided.  The  underlying  neuras- 
thenia and  pulmonary  or  heart  affections  should  receive  therapeutic 
attention.  In  atony  with  hyperacidity,  strychnin  sulphate,  -^^  of  a 
grain,  with  extract  of  belladonna,  ^^jj  of  a  grain  three  times  daily,  and 
electricity  can  be  recommended.  During  the  attack  itself  speedy 
evacuation  of  the  stomach  by  the  tube  and  of  the  bowel  by  warm- 
water  irrigation  are  the  most  effective  means  of  treatment. 

The  patients  will  usually  not  object  to  the  tube  in  these  attacks, 
because  their  suffering  and  want  of  air  is  so  great  that  the}^  are  willing 
to  undergo  anything  to  be  relieved ;  but  when  it  can  not  be  used  on 
account  of  heart  or  lung  trouble,  emetics  should  not  be  used  either, 
because  they  are  more  depressing  upon  the  heart  than  the  use  of  the 
tube.  When  the  heart  is  sound  and  emesis  is  absolutely  indicated, 
we  recommend  the  following : 

K  .      Pulvis  ipecac, 1. 5         gr.  xxiij 

Antimon.  et  potass,  tartrate, 0.05       gr.  ^.  M. 

SiG. — Make  two  powders,  to  be  taken  one-half  hour  apart. 

Prompt  emesis  may  be  effected  by  the  use  of  apomorphin,  hypo- 
dermically,  in  doses  of  y q-  of  a  grain ;  but  in  most  cases  the  vomiting 
unfortunately  continues  for  some  time  after  the  stomach  is  evacu- 
ated ;  it  is,  therefore,  not  recommended  for  this  purpose. 

The  Influence  of  Nervous  Diseases  upon  the  Stomach. — This 
subject  will  be  considered  in  connection  with  the  various  nervous 
disorders  of  digestion.  It  is  a  well-known  fact  that  emotional  ex- 
citement may  cause  an  alteration  in  the  gastric  secretions,  and  that 


386  MALARIA    COMPLICATING   GASTRIC   DISEASES. 

intense  nervous  depression  may  produce  gastric  distress,  fullness, 
pressure,  eructation,  nausea,  constipation  or  diarrhea,  meteorism, 
and  tenesmus.  Mental  overexertion  may  lead  to  nervous  dj-spepsia. 
Anatomical  alterations  in  the  central  nervous  s^^stem  may  be  ac- 
companied by  motor,  secretory,  and  resorptive  disturbances.  In  this 
connection  we  refer  again  to  the  gastric  disturbances  occurring  with 
tabes,  and  to  the  fact  that  Koch  and  Ewald  caused  gastric  hemor- 
rhages by  cutting  the  spinal  cord  ("Khnik  d.  Verdauungskrank- 
heiten,"  he.  cit.).  Brown-Sequard  and  Schiff,  as  well  as  Ebstein 
("Archivf.  exper.  Pathol.,"  Bd.  ii,  S.  183),  produced  gastric  hemor- 
rhage after  experimental  injuries  to  the  anterior  corpora  quadri- 
gemina.  We  have  personally  observed  submucous  hemorrhages  and 
small  areas  of  necrosis  in  the  stomach  eight  days  after  section  of 
one  or  both  vagi  in  cats,  dogs,  rabbits,  and  guinea-pigs.* 

Malaria. — It  is  a  ver\^  well-known  fact,  and  generally  accepted  by 
the  physicians  of  the  Southern  and  Eastern  States,  that  malaria  very 
often  complicates  gastric  diseases,  and  may  even  be  an  underlying 
cause.  It  is  very  probable  that  a  malarial  state  of  the  blood  may  be 
instrumental  in  causing  gastric  ulcer,  which  in  this  case  has  been 
asserted  by  London  to  be  due  to  pigment  emboli.  In  a  case  of  per- 
nicious malarial  fever  that  died  at  Bay  View  Hospital  there  was  found 
an  abundant  deposit  of  pigment  between  the  peptic  ducts,  and  also 
within  and  between  the  cells  of  the  ducts.  At  our  clinic  it  is  a  stand- 
ing rule  to  examine  all  persistent  cases  of  stomach  trouble  for  the 
presence  of  the  malarial  parasite  in  the  blood.  For  the  character- 
istics of  this  organism,  and  the  methods  of  examination,  we  refer  to 
the  article  by  AV.  H.  Welch  and  William  S.  Thayer,  in  the  "Loomis- 
Thompson  System  of  ^Medicine,"  and  also  to  the  able  monographs  of 
AV.  S.  Thayer  on  this  subject  ("Lectures  on  the  Malarial  Fevers," 
London,  Kimpton,  1898),  also  Tha^-er  and  Hewetson  ("The  Malarial 
Fevers  of  Baltimore,"  Johns  Hopkins  Press,  1895).  In  counties  of 
the  eastern  shore  of  Virginia  malarial  gastralgia  is  frequent.  Malaria 
does  not,  as  a  rule,  affect  the  secretion  or  motility,  except  in  the  vari- 
ous forms  of  pernicious  malarial  fever,  f     In  gastric  troubles  showing 

*If  both  vagi  are  intersected,  the  right  one  must  be  reached  beneath  the  origin  of 
the  recurrent  laryngeal  nerve  to  preserve  the  sensibility  of  the  respiratory  passages. 

t  A  very  reliable  and  accurate  Southern  colleague  informed  us  of  a  case  of  periodical 
hematemesis,  which  he  had  observed  near  Savannah,  occurring  every  third  day,  which 
was  cured  by  quinin.  A  form  of  the  algid,  pernicious  malarial  fever  is  called  by  some 
Southern  doctors  "gastric  malarial  fever." 


INFLUENCE    OF    ANEMIA    AND    CHLOROSIS    ON    STOMACH.  387 

any  periodicity,  or  microscopic  or  clinical  evidence  of  malaria,  quinin 
should  be  promptly  administered,  and  if  not  effective  within  twelve 
hours,  the  hydrobromate  of  quinin  should  be  injected  hypodermically. 

Dr.  Hans  Herz,  in  his  recent  work  ("Disturbances  of  Digestion  as 
a  Cause  and  Consequence  of  other  Diseases"),  does  not  mention 
malaria  as  a  cause  of  disease  of  the  stomach. 

Anemia  and  Chlorosis. — The  relation  between  pernicious  anemia 
and  atrophy  of  the  stomach  has  been  considered,  and  the  claim  of 
Austin  Flint  to  the  priority  of  this  clinical  association  has  been  em- 
phasized in  the  chapter  on  Achylia  Gastrica.     Anemia  and  chlorosis 
are  influential  etiological  factors  in  the  causation  of  gastric  diseases, 
if  they  are  primary  conditions.     This  relation  of  the  two  states  is  very 
difficult  to  estabhsh  and  probably  very  rare.     Hayem  ("Des  Altera- 
tions du  chimisme  Stomacal  dans  la  Chlorose,"   "Bulletin  Med.," 
1 89 1,  No.  87)  asserts  that  the  alterations  in  the  stomach  and  intes- 
tines are  the  primary  cause.     Kwald  and  Rosenheim  maintain  that 
the  digestive  disturbances  may  be  the  results  and  not  causes  of  the 
anemia.     There  are,  undoubtedly,  cases  in  which  the  anemia  is  the 
cause,  and  others  in  which  it  is  the  result.     In  some  instances  the 
treatment  will  throw  light  on  this  causative  relation.     If  the  secre- 
tory and  motor  functions  of  the  stomach  become  normal  with  the 
cure  of  undoubted  anemia,  the  gastric  disturbance  was  the  result  of 
the  state  of  the  blood;  but  if  the  secretory  and  motor  disturbances 
are  marked,  and  perhaps  of  long  standing,  and  examinations  show 
only  a  slight  deviation  from  the  normal  state  of  the  blood,  the  diges- 
tive disturbance  is  the  primar}^  one.     Often  it  is  possible,  when  pa- 
tients remain  under  observation  for  a  long  time,  to  observe  the  pro- 
gressive anemia  developing  as  a  sequence  to  gastro-intestinal  atroph)'. 
The  effect  of  syphilis  on  gastric  digestion  has  been  considered  in  a 
separate  chapter. 

Respiratory  Organs — Mouth,  Nose,  Pharynx,  and  Larynx.— 
Numerous  inflammations  of  these  parts  may  cause  invasion  of  the 
stomach,  by  direct  infection — i.  e.,  swallowing  of  infectious  material. 
Abnormahties  in  the  formation  of  the  gums,  cleft  palate,  deviations 
of  the  septum,  retracted  gums,  or  chronically  enlarged  tonsils  may, 
by  causing  one  of  the  many  forms  of  stomatitis,  or,  compelling  mouth- 
breathing,  bring  on  gastric  disturbance.  Stenoses  of  the  nasal  pas- 
sages in  gastric  sufferers  imperatively  demand  correction;  in  short, 
all  conditions  leading  to  mouth-breathing  may  induce  dyspepsia.  If 
this  is  the  case  with  simple  catarrhal  changes,  it  is  of  course  much 


388  ElfFECT   OF   PULMONARY   DISEASES    ON   THE    STOMACH. 

more  serious  with  carcinoma,  syphilis,  tuberculosis,  or  other  destruc- 
tive processes  (noma)  about  the  mouth,  nose,  throat,  larynx,  and 
antrum  of  Highmore. 

In  persistent  gastric  hyperacidities  we  have  frequently  observed 
what  may  be  termed  a  reflex  pharyngitis  and  posterior  nasal  catarrh, 
which  were  permanently  cured  by  treatment  of  the  hyperacidity 
after  direct  throat  and  nose  treatment  had  failed.  The  amount  of 
mucus  in  the  pharynx  became  largest  when  the  gastric  acidity  was 
highest ;  at  this  period  the  hawking  and  spitting  were  incessant ;  they 
became  less  as  the  acidity  was  reduced  either  by  normal  evacuation 
of  the  stomach  or  the  use  of  alkalies.  The  latter  were  in  some  cases 
poured  in  through  the  stomach-tube,  when  their  beneficial  action  on 
the  pharyngeal  mucous  flow  was  also  very  evident. 

Pulmonary  Diseases. — The  most  prominent  among  these  is  pul- 
monary tuberculosis.  W.  Fenwick  found  gastritis  to  be  present  in 
nearly  all  the  cases  of  pulmonary  tuberculosis,  chronic  bronchitis, 
emphysema,  and  acute  pneumonia.  He  asserts  that  in  diseases  of 
the  brain  no  gastric  involvement  was  observed  by  him  ("Virchow's 
Archiv,"  1889,  Ed.  cxviii,  S.  187) ;  he  found  gastritis  in  eleven  cases 
out  of  fifteen  of  phthisis.  Marfan  ("Troubles  et  Lesions  Gastriques 
dans  la  Phthisic  Pulmonaire,"  Paris,  1887)  found  but  five  cases  in 
sixty-one  of  tuberculosis  in  which  the  gastric  symptoms  preceded  the 
pulmonary.  It  is  very  difficult  to  decide,  when  a  dyspeptic  is  at  the 
same  time  affected  with  pulmonary  tuberculosis,  which  trouble  is 
primary.  As  a  rule,  diseases  limited  to  the  stomach  can  not  so 
weaken  the  general  state  of  health  as  to  predispose  to  pulmonary 
tuberculosis.  Rapid  exhaustion  from  localized  gastric  diseases 
occurs  only  in  carcinoma,  which  is  in  itself  rapidly  fatal  before  lung 
trouble  is  developed  to  any  great  extent;  but  when  the  gastric  dis- 
ease is  associated  with  intestinal  disturbances,  so  that  the  digestion 
is  very  much  interfered  with,  general  nutrition  ma}^  be  so  impover- 
ished that  tuberculosis  can  be  more  readily  acquired.  Hutchinson 
("The  Morbid  States  of  the  Stomach  and  Duodenum,"  London,  1 878) 
publishes  an  analysis  of  a  large  number  of  cases,  and  states  that  the 
digestive  disturbances  precede  the  tubercular  infection  in  about  one- 
third  of  the  cases.  It  is  in  these  cases  of  suspected  pulmonary  dis- 
ease, associated  with  digestive  troubles,  that  the  ability  of  a  good 
auscultator  will  tell.  Gastro-enterologists  should  not  fail  to  avail 
themselves  of  their  experience  in  auscultation  and  percussion. 
Whenever  sputum  can  be  obtained,  it  should  be  examined  for  tuber- 


RELATION  BETWEEN  PULMONARY  AND  GASTRIC  DISEASES.       389 

cle  bacilli.  The  state  of  the  gastric  secretion  and  the  motor  function 
in  tuberculosis  have  been  studied  by  Hdinger  (loc.  cit.),  Rosenthal 
(loc.  cit.),  Shetty  {loc.  cit.),  O.  Brieger  {loc.  cit.),  Immermann  {loc.  cit.), 
Hildebrandt  {loc.  cit.),  and  Einhorn  {loc.  cit.).  The  state  of  the  secre- 
tory and  motor  functions  in  pulmonary  phthisis  varies,  in  our  expe- 
rience, with  the  stage  of  the  pulmonar}^  disease.  In  the  incipient 
stages  of  phthisis,  secretion  and  motility  may  be  normal  for  a  long 
time;  they  will  become  more  and  more  deranged  as  the  pulmonary 
trouble  progresses,  so  that  in  the  final  stages  of  pulmonary  caseation, 
breakdown,  and  formation  of  cavities,  all  gastric  function  may  be  ex- 
tinguished. Brieger  {loc.  cit.)  states  that  in  the  initial  stages  the 
cases  of  normal  and  disturbed  secretion  are  about  equally  divided. 
In  moderately  severe  cases  secretion  was  normal  only  in  one-third, 
or  33  per  cent. ;  in  the  remainder  secretion  was  variable,  but  gener- 
ally depressed.  In  6.6  per  cent,  there  was  no  secretion  whatever. 
In  advanced  cases  of  phthisis  secretion  was  normal  only  in  16  per 
cent,  of  the  cases.  It  was  more  or  less  defective  in  the  rest  of  the 
cases,  and  in  9.6  per  cent,  there  was  complete  arrest  of  secretion. 
Immermann  {loc.  cit.)  found  the  gastric  peristalsis  normal  in  fifty- 
three  out  of  fifty-four  tests,  whereas  Klemperer  {loc.  cit.)  claims  to 
have  found  marked  inhibition  of  the  peristalsis  by  his  method.  The 
amount  of  gastric  secretion  and  the  state  of  the  peristalsis  are  not 
satisfactory  exponents  of  the  digestive  powers  of  phthisical  patients. 
The  only  correct  way  to  find  out  whether  such  patients  have  diges- 
tive power  sufficient  to  maintain  the  nitrogen  equilibrium  is  by  quan- 
titative experiments  on  vietabolism.  B}^  giving  weighed  amounts  of 
certain  foods  after  the  nitrogen  balance  has  been  established,  and 
determining  the  quantity  that  is  digested  and  the  quantity  that  is 
excreted  undigested,  together  with  careful  determination  of  the 
amount  of  nitrogen  in  the  urine,  we  have  been  able  to  discover  that 
tuberculous  patients  (first  stage  of  pulmonary  tuberculosis),  with 
absolute  achylia  gastrica,  may,  with  care  as  to  diet,  still  be  able  to 
maintain  their  nitrogen  equilibrium,  provided  the  gastric  peristalsis 
was  preserved.  In  future  the  exact  state  of  the  pulmonary  disease, 
its  duration  and  extent,  together  with  a  statement  of  the  condition  of 
all  the  remaining  organs,  would  be  desirable,  if  the  correlation  exist- 
ing between  gastric  and  pulmonary  troubles  is  to  be  put  upon  a  basis 
of  approximate  exactness.  Although  the  treatment  of  the  tubercu- 
losis is  the  main  object,  it  will  be  impossible  to  maintain  nitrogen 
equilibrium  with  a  defective  digestive  apparatus ;  it  is,   therefore, 


39©  INFLUENCE   OF   OTHER   DISEASES   ON   THE   STOMACH. 

essential  that  the  functions  of  the  stomach  should  be  improved  as  far 
as  possible.  In  this  way  a  system  of  forced  alimentation,  such  as  has 
been  very  successfully  employed  by  Debove  {loc.  cit.),  Dettweiler, 
Liebermeister,  I^eyden,  Riihle,  and  Peiper,  may  become  possible.  In 
each  individual  case  the  diet  and  the  medicine  should  be  ordered 
according  to  the  state  of  the  gastric  functions  found  from  test-meals. 
We  have  had  three  patients  affected  with  pulmonary  tuberculosis 
and  gastritis  at  the  Maryland  General  Hospital  during  the  winter  of 
1896  and  1897,  who  gained  considerably  in  weight  by  treatment  of 
the  existing  gastritis.  One  patient  with  pulmonary  tuberculosis  and 
a  tubercular  rectal  fistula  gained  fourteen  pounds  in  two  months 
under  daily  lavage  and  administration  of  HCl  and  strychnin,  together 
with  nutritious  diet.* 

Diseases  of  the  Heart. — We  have  already  spoken  of  the  effect  of 
gastric  disturbances  in  producing  tachycardia,  bradycardia,  and 
arrhythmia.  The  diseases  of  the  stomach  which  are  caused  by  val- 
vular affections  of  the  heart  are  brought  about  by  the  venous  stasis 
and  passive  congestion.  Under  the  head  of  chronic  gastritis  we  have 
spoken  of  the  efficacy  of  digitalis  when  valvular  disease  is  in  clear 
etiological  association  with  the  gastric  affection.  Concerning  the 
state  of  the  secretion  in  heart  diseases,  there  is  no  agreement  in  the 
observations  thus  far  reported.  In  twenty  patients  with  heart  dis- 
ease Adler  and  Stem  ("Berl.  klin.  W^ochenschr.,"  1S89,  No.  49)  found 
free  HCl  always  present  in  sixteen,  variable  in  two,  and  alwa3"s  absent 
in  two  cases.  Hiifler  states  that  in  ten  cases  of  mostly  valvular 
lesions  suppression  of  the  secretion  of  HCl  and  absence  of  albumin 
digestion  were  found  nine  times  and  hyperacidity  in  a  single  case. 
Most  of  his  patients  are  stated  to  have  been  in  the  stage  of  perfect 
cardiac  compensation.  These  observations  of  Hiifler  are  not  intelli- 
gible in  the  light  of  the  pathological  physiology  of  cardiac  diseases ; 
for  perfect  compensation  means  that  the  arterial  and  venous  pressure 
in  aU  the  organs  is  normal ;  under  this  state  we  can  not  conceive  of 
any  passive  congestion  in  the  stomach.  Germain  See  held  that  the 
initial  "Gastricismus  "  was  the  earliest  sign  of  a  valvular  trouble; 
that  evidence  of  passive  congestion  may  be  present  when  there  is  as 
yet  no  murmur  or  accentuated  sound.  By  perfect  compensation  we 
mean  the  natural  compensation  of  the  heart-muscle,  not  the  transient 


*  The  tuberculous  fistula  was  treated  by  Dr.  Samuel  T.  Earle,  and  healed  up  com- 
pletely before  the  patient  left  the  hospital. 


DYSPEPSIA   AS    A   SYMPTOM    OF    GOUT    AND    RHEUMATISM.        39 1 

improved  tonus  effected  by  a  drug  (digitalis).  In  our  experience 
gastric  secretion  was  normal  in  eight  cases  of  mitral  regurgitation, 
two  cases  of  aortic  regurgitation,  and  two  cases  of  mitral  insufficiency, 
with  perfect  compensation.  As  soon  as  compensation  becomes  de- 
fective, the  gastric  symptoms  make  their  appearance,  and  secretion 
is  found  altered. 

Diseases  of  the  Liver. — The  close  anatomical  and  physiological 
relationship  between  the  liver  and  the  stomach  explains  the  sympa- 
thetic manner  in  which  diseases  of  one  organ  frequently  reflect  upon 
the  other.  Excepting  in  the  diseases  of  the  biliary  passages  and  gall- 
bladder, it  is  impossible  to  say  which  organ  is  primarily  affected. 
During  the  passage  of  gall-stones  gastric  secretion  is  suppressed ;  this 
suppression  is  due  to  a  reflex  influence  caused  by  the  intense  pain. 
We  have  analyzed  the  vomited  matter  which  was  brought  up  during 
attacks  of  biliary  colic.  In  three  cases  it  was  neutral,  very  faintly 
acid  (=  6°,  decinormal  NaOH);  in  one  case  it  showed  presence  of 
combined  HCl — no  free  HCl;  in  two  cases  it  was  alkaline  (=  8°-io°, 
^  H2SO4) .  The  alkalinity  of  this  vomit  was  not  due  to  the  presence 
of  bile  or  pancreatic  juice,  because  they  were  found  to  be  absent. 
Cases  of  cirrhosis  of  the  liver,  and  even  of  cancer  of  the  liver,  may  run 
a  latent  course  for  a  long  time,  the  symptoms  being  those  of  chronic 
gastritis.  We  have  made  118  analyses  of  gastric  contents  in  cases  of 
catarrhal  jaundice  ("Bulletin  of  the  Maryland  University  Hospital," 
vol.  Ill,  No.  2,  p.  30).  In  twenty  cases  of  icterus  (catarrhal)  free  and 
combined  HCl  were  absent  in  twelve ;  free  HCl  absent  but  combined 
HCl  present  in  four ;  free  and  combined  HCl  present  in  six.  It  would 
"of  course,  be  important  to  know  whether  those  cases  in  which  free 
HCl  was  absent  during  the  icterus  had  chronic  gastritis  before  the 
jaundice.  In  six  of  these  eight  cases  free  HCl  was  found  two  months 
after  the  recovery  from  the  attack ;  at  that  time  there  were  no  evi- 
dences of  gastritis. 

Gout  and  Rheumatism. — Burney  Yeo  claims  that  dyspepsia  is  a 
frequent  and  prominent  manifestation  of  gout  ("Brit.  Med.  Jour.," 
Jan.  7  and  14,  1888).  This  specific  gouty  disorder  of  the  stomach  is 
claimed  to  exist  in  states  of  uric  acid  diathesis  by  a  number  of  con- 
tributors to  British  medical  journals.  Ewald  states  that  he  has  not 
met  with  a  single  case  of  true  gout  with  coincident  gastric  disturb- 
ances, but  that  he  has  seen  numerous  such  examples  in  chronic  artic- 
ular rheumatism,  in  which  the  dyspepsia  was  so  marked  that  the  pains 
in  the  joints  were  comparatively  insignificant.  Anomalies  of  secre- 
26 


392  INFLUENCE    OF    OTHER   DISEASES    ON   THE    STOMACH. 

tion  in  gout  have  been  repeatedly  observed  by  us.  The  most  fre- 
quent secretory  trouble  is  hyperacidity. 

Alexander  Haig  recognizes  gout  of  the  intestines  and  cecum  ("Uric 
Acid  as  Causation  in  Disease,"  pp.  330  and  623),  also  gastro-intestinal 
irritation,  as  a  cause  of  uricacidemia  {loc.  cit.,  p.  49).  Without  enter- 
ing into  the  literature  of  the  relation  of  uric  acid,  gout,  and  rheuma- 
tism to  gastro-intestinal  diseases,  we  wish  to  say  that  the  nature  of 
these  diseases  is  still  too  obscure  to  permit  of  any  exact  scientific 
determinations  of  the  relation  in  question.  Gout  and  uric  acid  di- 
athesis occur  in  the  same  constitutions,  suggesting  that  the  conditions 
are  identical.  The  author  has  had  occasion  to  study  numerous  cases 
of  gastralgia  that  yielded  to  nothing  but  salicylate  of  soda  and  col- 
chicum,  also  many  cases  of  enteritis  that  were  improved  by  diet  free 
from  uric  acid  (milk) ;  still,  these  observations  do  not  convince  him 
of  the  correctness  of  the  terms  "gout  of  the  stomach  or  intestines" 
which  Haig  uses. 

Diabetes  Mellitus. — Although  there  is  no  constancy  in  the  char- 
acter of  the  secondary  gastric  symptoms  accompanying  diabetes, 
there  are  few  cases  of  this  disease  in  which  the  stomach  is  not  in- 
volved. Diabetes  affects  the  stomach  in  two  ways  principally: 
either  by  arresting  its  functions  through  auto-intoxication  or  by  pro- 
duction of  gastritis.  The  presence  of  great  thirst,  polyuria,  poly- 
phagia, ocular  disturbances,  pruritus,  emaciation,  usually  means 
coexistent  gastric  involvement.  Rosenstein  and  Gans  have  exam- 
ined the  gastric  functions  in  diabetes  (Rosenstein,  ' '  Berl.  klin.  Woch- 
enschr.,"  1890,  No.  13).  Their  results  show  that  the  disturbances, 
although  present,  show  no  constancy  in  type.  The  polyphagia  and" 
polydipsia  of  diabetes  have  been  known  to  cause  gastrectasia.  Our 
personal  observation  on  diabetic  patients  indicates  that,  as  a  rule, 
peristalsis  and  secretion  are  normal.  Our  material  in  this  line  has 
been  limited.  Eight  normal  tests  of  both  functions  were  found  in 
twelve  cases  studied.  In  the  abnormal  cases,  hyper-,  sub-,  and 
anacidity  were  found  in  different  patients,  and  in  the  same  patient 
at  different  times  (heterochylia) .  There  is  no  sugar  present  in  the 
gastric  secretion  (Kiilz).  The  disease  has  been  known  to  begin  with 
severe  gastric  symptoms  from  the  onset,  and  Teschemacher  advises 
that  the  urine  be  examined  for  sugar  in  all  cases  where  severe  acute 
gastritis  repeatedly  occurs  without  a  traceable  cause. 

Diseases  of  the  Kidney. — The  stomach  is  always  more  or  less 
affected  in  renal  diseases,  and  the  symptoms  of  disturbed  gastric 


GASTRIC    DIGESTION   AND    DISEASES    OF    THE    KIDNEYS.  393 

digestion  very  often  appear  long  before  albumin  is  present  in  the 
urine.  In  the  "Maryland  Medical  Journal,"  July  24  and  31,  and 
August  7,  1897,  I  have  reported  three  cases  of  nephritis  which  were 
probably  due  to  chronic  auto-intoxication  from  the  gastro-intestinal 
tract.  In  this  connection  I  wish  to  emphasize  the  gastric  diseases 
which  are  caused  by  preexisting  affections  of  the  kidneys.  Natur- 
ally, it  is  unavoidable  that  a  certain  amount  of  auto-intoxication  will 
accompany  the  association  of  renal  with  gastric  disease,  no  matter 
which  is  the  primary  affection.  Albu  (loc.  cit.)  and  Biernacki  ("Berl. 
klin.  Wochenschr.,"  1891,  No.  25  and  No.  26)  emphasize  the  influence 
of  retained  metabolic  products  in  producing  gastric  disturbances. 
These  retained  products  of  metabolism  injure  the  stomach  in  two 
ways :  (i)  By  acting  as  toxins  through  the  vascular  channels  directly 
upon  the  parenchyma  of  the  gastric  walls,  and  (2)  by  irritation  of  the 
surface  of  the  stomach,  since  they  are  very  frequently  excreted  in  this 
manner.  Fenwick  {loc.  cit.)  states  that  the  gastric  mucosa  is  capa- 
ble of  secreting  urea  like  the  intestinal  mucosa,  and  that  the  excretion 
of  this  product  causes  an  acute  catarrh  of  the  gastric  glands.  I  have 
analyzed  the  vomit  of  two  patients  afflicted  with  chronic  interstitial 
nephritis,  and  repeatedly  found  urea  or  ammonia  in  it.  If  the  total 
nitrogen  excreted  in  the  urine  is  approximately  normal,  the  vomit 
does  not  contain  urea,  in  my  experience.  This  would  indicate  that 
the  gastro-intestinal  canal  is  not  called  upon  to  vicariously  secrete 
urea,  until  the  kidneys  can  no  longer  do  so.  A  variety  of  gastric 
diseases  have  been  found  to  exist  in  connection  with  chronic  Bright's 
disease.  We  shall  see  in  the  clinical  part  that  acute  and  chronic  gas- 
tritis, fatty  degeneration  of  the  glandular  epithelium,  and,  according 
to  Ewald,  amyloid  degeneration  may  occur.  Edema  of  the  gastric 
walls  is  a  very  rare  complication.  The  effects  of  floating  kidney  in 
producing  stenosis  of  the  duodenum  have  been  considered  in  the 
chapter  on  Enteroptosis.  Allan  A.  Jones  ("Gastric  Conditions  in 
Renal  Disease,"  "New  York  Med.  Jour.,"  Jan.  19,  1895)  has  fre- 
quently found  suppression  of  gastric  secretion  in  patients  with 
kidney  diseases.  Einhorn  reports  a  case  of  achylia  gastrica  due  to 
renal  calculus,  which  had  existed  for  a  long  time.  After  removal 
of  the  stone  by  operation,  the  gastric  symptoms  at  once  disappeared. 
According  to  Biernacki,  the  secretory  function  is  arrested  in  renal 
affections. 

Renal  Disturbances  in  Connection  with  Digestive  Diseases. — 
During  disturbed  digestion  a  number  of  toxic  substances  formed  in 


394  IXFLUEXCE    OF    OTHER   DISEASES    OX   THE    STOMACH. 

the  gastro-intestinal  canal  reach  the  kidneys  through  vascular  chan- 
nels, and  are  there  excreted.  Substances  ver\"  closely  related  to 
serum-albumin  find  their  way  out  through  the  kidneys :  for  instance, 
albumoses,  egg-albumen,  and  hemoglobin.  Under  this  increased 
work  the  kidneys  may  become  diseased.  In  experimental  injections 
of  egg-albumen  it  has  been  observed  that  more  albumen  is  excreted 
than  was  injected.  If  the  disturbance  persists  for  a  long  time,  albu- 
minuria, excretion  of  epithelia,  and  leukocytes  become  more  perma- 
nent. 

There  are  abnormal  conditions  of  the  blood  in  which  the  excretion 
of  the  urine  may  become  totally  suppressed :  for  instance,  the  blood 
disintegration  after  grave  icterus  and  extensive  burns. 

There  are  two  kinds  of  renal  albuminuria :  (i)  Those  due  to  patho- 
logical changes  in  the  parenchyma  or  innerv^ation  or  vascular  supply 
of  the  kidne}",  and  (2)  the  hematogenous  variety,  in  which  a  primarily 
healthy  kidney  ser^^es  as  a  purifying  organ  to  excrete  useless  albu- 
minous substances.  Both  varieties  may  occur  combined,  for  the 
same  cause  may  alter  blood  and  kidney  simultaneously  (scarlatina, 
typhoid  fever),  and  continued  excretory  overburdening,  b}"  elimina- 
tion of  albumin,  may  secondarily  lead  to  inflammatory'  changes  in  the 
kidney ;  this  probably  occurs  where  intermittent  albuminuria  gradu- 
ally passes  over  into  interstitial  nephritis.  According  to  Senator, 
albumin  very  often  occurs  in  the  urine  after  excessively  albuminous 
meals,  the  so-called  physiological  albuminuria.  It  is  conceivable 
that  the  albuminous  food  has  been  too  abundant  or  has  not  under- 
gone a  normal  or  sufficient  proteolysis,  and  really  enters  the  circula- 
tion as  a  foreign  substance;  for  there  are  ver\^  great  A'arieties  of 
albumins  and  our  imperfect  chemical  methods  do  not  permit  us  to 
distinguish  between  them.  So-called  "dyspeptic  albuminuria" 
occurs  occasionally  in  a  transient  wa}^,  in  connection  with  chronic 
gastric  diseases,  particularly  dilatations,  without  being  followed  by 
inflammatorv^  changes  in  the  kidney.  Miiller  found  albuminuria  in 
72  per  cent,  of  gastric  cancers ;  in  cancers  of  other  organs  of  the  body 
lie  found  it  in  only  35  per  cent.  The  author  has  discovered  albumin- 
uria in  75  per  cent,  of  his  gastric  cancer  cases ;  so  it  would  appear  that 
cancers  of  the  stomach  must  be  assigned  a  special  influence  in  the  pro- 
duction of  this  abnormality.  V.  Xoorden  discovered  albuminuria 
after  severe  gastralgias  with  gastric  ulcer  and  also  after  gastric  hemor- 
rhage. In  explanation  of  these  phenomena  we  have  nothing  but 
theories,  prominent  among  which  are  the  auto-intoxication  and  the 


DIGESTIVE    DISTURBANCES   AND    RENAL    DISEASES.  395 

reflex  theory.  Anemia  and  cachexia  may  be  brought  on  by  all  long- 
standing gastro-intestinal  diseases,  and,  when  once  established,  lead 
to  nephritis.  Albuminuria  has  been  assigned  to  rapid  fall  of  arterial 
pressure  during  severe  diarrheas.  Toxic  and  bacterial  albuminuria 
has  been  described  as  due  to  toxins  and  bacteria  originated  in  the  in- 
testines. When  the  intestines  and  stomach  are  inflamed,  the  process 
of  proteolysis  is  defective,  and  albuminous  bodies  enter  the  circula- 
tion imperfectly  prepared,  and  must  be  excreted  again,  damaging  the 
renal  structures  secondarily.  Toxins,  in  passing  from  the  intestines 
into  the  blood,  are  supposed  to  alter  the  structure  of  the  blood  albu- 
min-molecule, which  then  passes  out  through  the  kidney — one  form 
of  hematogenous  albuminuria. 

Digestive  Disturbances  in  Connection  with  Renal  Diseases. — 
Both  in  acute  and  chronic  nephritis  digestive  symptoms  may  be 
entirely  absent.  In  some  cases  digestive  disturbances  are  pro- 
nounced before  the  albuminuria  can  be  detected.  Sudden  severe 
nausea  and  vomiting,  particularly  when  occurring  with  headache,  in 
absence  of  evident  cause,  is  suggestive  of  nephritis.  Vomiting  is  the 
most  frequent  motor  disturbance  of  the  stomach,  in  association  with 
kidney  disease,  and  three  kinds  are  recognizable :  (i )  A  copious  watery 
vomit,  containing  sparingly  of  mucus,  the  total  acidity  of  which,  in 
our  experience,  is  6°  to  8°  (^NaOH),  containing  no  free  nor  combined 
HCl.  The  specific  gravity  is  1002 ;  it  generally  occurs  in  the 
morning,  before  breakfast.  (2)  Hematemesis;  it  is  rare  that  large 
amounts  of  blood  are  vomited.  (3)  Vomit  containing  constituents 
of  the  urine,  particularly  urea. 

We  have  discovered  urea  as  such  in  the  vomit  of  chronic  nephritis 
(to  test  this  we  took  only  such  cases  as  showed  a  deficient  excretion 
of  urea),  but  more  frequently  carbonate  or  chloride  of  ammonia.  The 
vomit  becomes  alkaline,  and  has  a  penetrating,  ammoniacal  odor. 

The  secretory  gastric  function  varies ;  there  may  be  normal,  hyper-, 
sub-,  or  anacidity.  We  know  that  many  gastric  symptoms  are  trace- 
able to  cachectic  conditions — anemia  and  hydremia;  therefore,  all 
concomitant  defects  of  digestion  can  not  logically  be  assigned  to  the 
nephritis  when  these  states  are  coexistent.  Both  organs  may  be 
diseased  from  the  same  cause. 

Retention  of  nitrogenous  constituents  of  the  urine  (urea,  uric  acid, 
etc.)  does  not  occur  in  all  cases  of  nephritis ;  but  when  this  elimina- 
tion is  subnormal,  a  vicarious  excretion  of  these  products  through  the 
gastro-intestinal  mucosa  may  occur  and  has  been  observed  by  the 


396  GASTRIC   DISE:aSES  AND  THOSE   OF   OTHER   ORGANS. 

author.  Uric  acid  has  been  found  in  such  small  traces  that  it  may 
be  regarded  as  the  uric  acid  contained  in  the  food  before  it  was  eaten. 
But  urea  occurs  in  quantities  much  in  excess  of  what  could  be  in  the 
food,  and  in  morning  vomit  before  food  was  taken.  It  is  self-evident 
that  the  passage  of  urea  which  is  decomposable  into  ammonium  car- 
bonate through  the  gastric  mucosa  must  severely  injure  the  secretory 
cells,  and  even  cause  gastritis.  A  certain  class  of  nephritis  cases  ex- 
hibit vomiting  that  can  be  called  nervous  or  uremic;  the  causes  of 
irritation  of  the  central  nervous  organs  and  those  of  the  uremia  in 
these  cases  are  closely  related,  perhaps  identical. 

There  are  a  large  number  of  digestive  disturbances  in  association 
with  albuminuria,  or  rather  with  nephritis,  which  can  not  be  attri- 
buted to  anemia,  cachectic,  nervous,  or  uremic  conditions,  nor  even 
to  lessened  excretion  of  water  or  nitrogen.  The  author  does  not  look 
upon  urea  as  the  essential  and  only  dangerous  substance  that  is 
retained,  nor  upon  albumin  as  the  only  essential  material  that  is  lost 
in  nephritis.  There  are  toxins,  or  rather  bodies,  the  result  of  retro- 
gressive metamorphosis,  which  are  retained  at  a  time  when  the  total 
nitrogen  eliminated  is  still  normal;  these  poisonous  materials  seek  a 
way  out  through  the  gastro -intestinal  canal,  and  may  bring  about 
catarrhal,  inflammatory,  and  ulcerative  conditions  in  the  intestines. 
J.  Fischer  and  Grawitz  have  recently  described  uremic  intestinal 
ulcers,  and  Marchiafava  describes  hemorrhagic  gastric  erosions  lead- 
ing to  hematemesis  due  to  the  same  condition.  The  so-called  cyclic 
albuminuria  is  a  very  vague  conception:  digestive  disturbances  are 
said  to  occur  in  connection  with  it.  But  it  is  not  easy  to  define  ex- 
actly what  cyclic  albuminuria  is.  Perhaps  latent  nephritis  breaking 
out  and  remaining  quiescent  alternately;  perhaps  hematogenous  or 
nervous  albuminuria.  Finally,  there  is  a  form  of  albuminuria  in 
which  the  urine  shows  high  specific  gravity,  little  albumin,  excessive 
excretion  of  uric  acid  and  urates  at  times,  but  rarely  oxalates,  and 
numerous  cylinders  or  hyaline  casts.  This  condition  Da  Costa  looks 
upon  as  a  disease  of  metabolism  in  which  both  albuminuria  and  diges- 
tive disturbances  are  the  expression  of  the  former.  Vomiting  has 
been  caused  by  painful  swelling  of  the  kidney  in  acute  inflammatory 
conditions.  The  relation  of  movable  or  floating  kidney  to  digestive 
diseases  has  been  considered  in  the  chapter  on  Enteroptosis. 

Relation  of  Digestive  and  Skin  Diseases. — There  can  be  no 
doubt  that  digestive  troubles  have  an  influence  in  the  production  of 
eczema,  urticaria,  erythema,  the  various  forms  of  acne,  and  pern- 


RElyATlON    BETWEEN   DIGESTIVE;   AND    SKIN   DISEASES.  397 

phigus;  but  there  is  only  doubtful  evidence,  vice  versa,  that  skin 
troubles  have  any  effect  upon  the  gastric  function,  excepting  exten- 
sive cutaneous  burns.  When  the  skin  has  been  destroyed  over  large 
areas,  duodenal  and  sometimes  gastric  ulcers  were  observed  to  de- 
velop. The  homeopaths  assume  a  great  many  digestive  troubles  to 
be  caused  by  so-called  "systemic"  itch,  and  Pedioux  ("L' Union 
Med.,"  1866,  p.  235)  considered  dyspepsia  an  expression  of  a  herpetic 
state  of  the  system.  These  inferences  are  too  absurd  to  be  considered 
seriously. 

The  relation  of  skin  and  digestive  diseases  may  be  considered  from 
three  aspects:  (i)  Skin  diseases  of  which  the  causes  apparently 
emanate  from  the  gastro-intestinal  tract;  (2)  digestive  diseases  the 
causes  of  which  apparently  emanate  from  the  cutaneous  surface;  (3) 
conditions  of  abnormality  simultaneously  occurring  in  both  skin  and 
digestive  tract,  due  apparently  to  some  common  cause.  The  track 
through  which  irritations  may  reach  the  skin  from  the  digestive  canal 
is  either  through  the  nerves  or  by  way  of  the  blood-vessels.  If  the 
disturbance  can  be  plainly  assigned  to  a  nervous  influence,  we  speak 
of  it  as  a  "reflex";  if  it  is  traceable  to  a  blood- vascular  influence,  it 
is  most  often  attributed  to  "auto-intoxication."  A  distinct  line  of 
separation  between  the  two  can  not  be  drawn,  as  it  is  not  even  certain 
whether  we  are  correct  in  assuming  this  classification.  In  some 
patients  urticaria  may  develop  in  a  very  few  minutes  after  the  inges- 
tion of  food;  in  some  others  that  manifest  an  idiosyncrasy  against 
certain  kinds  of  food-substances,  the  urticaria  has  been  known  to 
develop  immediately  after  touching  that  substance  to  the  mucosa  of 
the  mouth.  Now,  the  appearance  of  this  phenomenon  is  entirely  too 
rapid  to  be  assignable  to  the  blood  or  vascular  intermediation — it 
must  be  a  reflex.  This  nervous  reaction,  no  doubt,  takes  place  in 
many  forms  of  urticaria  and  erythemas,  in  the  cutaneous  eruptions 
that  follow  nervous  colics,  dentition,  and  those  that  occur  in  associa- 
tion with  intestinal  parasites. 

In  cases  of  acne,  however,  that  develop  in  the  course  of  chronic 
digestive  disturbances  and  in  the  pruritus  of  icterus  and  diabetes,  it  is 
more  probable  that  the  course  of  events  has  been  abnormal  putrefac- 
tions and  fermentations  in  the  intestinal  canal,  effecting  a  pathologi- 
cal condition  of  the  blood.  Singer  has  given  this  view  somewhat  of 
an  experimental  basis  by  demonstrating  the  increase  of  ethereal 
sulphates  in  the  urine  of  such  patients.  Albu  attributes  the  cuta- 
neous efflorescences  after  ingestion  of  certain  foods   (strawberries, 


398  GASTRIC    DISK  ASKS   AND   THOSE    OF    OTHKR   ORGANS. 

lobsters),  and  even  the  urticaria  after  copaiba  or  turpentine,  not  to 
these  substances  themselves,  but  to  the  results  of  a  gastro-intestinal 
catarrh  set  up  by  them. 

Digestive  diseases  in  etiological  relation  with  preexisting  skin  dis- 
eases are  chiefly  those  consequent  upon  exposure  of  the  skin  to  ex- 
tremes of  temperature,  the  gastric  and  intestinal  catarrhs  due  to  cold 
or  taking  cold,  and  the  (gastric)  duodenal  ulcers  following  bums. 

Pathological  conditions  in  which  both  the  skin  and  the  digestive 
tract  are  simultaneously  affected  are  represented  by  the  febrile  ex- 
anthemata— infectious  diseases  involving  both  the  skin  and  the 
alimentary  passage  (scarlatina,  measles,  typhoid,  variola,  etc.). 

Among  the  typical  eruptions  that  befall  both  tissues  are  the  ery- 
thema exudativum  multiforme,  erythema  bullosum  (Werman),  and 
erythema  nodosum  (Pospelow).  The  acute  and  subacute  phlyctenu- 
lar eruptions  (herpes  zoster)  may  occur  in  the  mouth  as  well  as  on  the 
epidermis.  Also  pemphigus  and  lichen  ruber  and  planus.  The 
unfortunate  sufferers  of  pemphigus  in  the  mouth  surface  are  easily 
mistaken  for  syphilitics  on  account  of  the  similarity  in  the  eruptions. 
The  phlyctenular  pemphigus  can,  however,  be  distinguished  by  its 
superficial  location  (subepidermal,  intra-epithelial),  the  acute  course, 
absence  of  lymph-gland  involvement  and  scar-formation,  and  the 
characteristic  phlyctenular  eruption  of  the  epidermis  as  soon  as  this 
makes  its  appearance.  Diseases  of  the  mouth  of  these  types  are,  as  a 
rule,  not  recognized  except  when  a  typical  skin  eruption  precedes  or 
follows  it.  (See  Schech,  "Krankheiten  d.  Mundhohle";  Kraus, 
"Krankheiten  d.  Mundhohle";  in  Nothnagel's  "Specielle  Pathol,  u. 
Therap.";  also  J.  Mikulicz  and  W.  Kiimmel,  "Die  Krankheiten  des 
Mundes." 

Very  curious  reciprocal  relations  have  been  observed  between  skin 
and  digestive  tract :  for  instance,  the  improvement  or  disappearance 
of  a  number  of  skin  diseases  after  severe  diarrheas  and  loss  of  blood 
from  hemorrhoids.  The  dermal  disease  sometimes  returns  when  the 
digestive  trouble  is  cured.  Scabies  has  been  cured  by  an  intervening 
diarrhea  in  this  way.  The  explanation  is  hypothetical,  but  there  is 
no  doubt  that  diarrheas  have  a  strong  derivative  influence  on  the 
circulation  in  the  skin.  Kobner  observed  a  case  of  pemphigus  vege- 
tans with  diarrheas ;  as  long  as  the  bowels  were  loose,  new  vegetations 
did  not  appear,  and  the  old  ones  showed  tendency  to  healing,  but 
when  the  diarrhea  ceased,  the  skin  pemphigus  became  aggravated. 
There  are  even  cases  on  record  where  long-standing  digestive  diseases 


UTERATURE.  399 

disappeared  with  the  sudden  eruption  of  a  cutaneous  affection.  Urti- 
caria and  dermatitis  have  been  reported  to  act  in  this  manner.  S. 
Fenwick  observed  sudden  cessation  of  severe  gastralgia  with  hyper- 
acidity on  the  appearance  of  an  eczema.  He  beheves  to  have  noticed 
this  association  of  hyperacidity,  gastralgia,  and  cutaneous  eczema 
frequently.  The  term  "eczema  of  the  stomach"  which  Fenwick 
uses,  in  this  connection,  seems  not  well  founded.  These  relations 
between  skin  and  digestive  tract  are  not  sufficiently  supported  by 
pathological  evidences  to  permit  of  exact  deductions.  Such  cases  are 
exceedingly  rare  in  our  experience.  Fenwick  supposes  that  the  epi- 
dermis and  lining  epithelium  of  digestive  tract  may  substitute  for  one 
another  in  the  excretion  of  toxins,  and  therefore  symptoms  may  dis- 
appear on  one  membrane  when  the  other  takes  up  the  excretory 
work. 

The  striking  way  in  which  certain  exceptional  forms  of  enteritis 
and  colitis  are  cured  by  arsenic,  after  other  treatment  has  failed,  is 
suggestive  of  the  existence  of  an  eruption  on  the  intestinal  mucosa, 
or  at  least  of  an  abnormal  condition  analogous  to  certain  of  the  skin 
diseases  referred  to.  The  functions  of  the  skin  are  imperfectly  under- 
stood, and  until  we  know  them  better,  the  above  relations  must 
remain  unintelligible.  The  skin  is  a  protective,  secretory  and  excre- 
tory, heat-regulating,  and  sensory  organ.  But  in  addition  to  all  these 
functions  it  seems  to  be  a  receptive  apparatus,  transformer  and  trans- 
mitter of  forms  of  energy  of  the  most  delicate  and  subtle  kind  ("Ther- 
apeutic Value  of  the  Solar  Rays,"  by  Albert  Adams,  "Phila.  Monthly 
Med.  Jour.,"   March,    1899.   P>    75)- 


LITERATURE 

ON   THE    CORRELATION   OF    DISEASES   OF  THE    STOMACH     TO    THOSE   OF 
OTHER   ORGANS. 

1.  Adler  und  Stern,  "Ueber  die  Magenverdauung  bei  Herzfehlern," 
"  Miinch.  med.  Wochenschr.,"  1889,  No.  33. 

2.  Bernstein,  Iwan,  "Die  Dyspepsie  der  Phthisiker,"  Inaug.  Dissert.,  Dor- 
pat,  1889. 

3.  Biernacki,  "  Ueber  das  Verhalten  des  Magens  bei  Nierenentziindung," 
"  Berl.  klin.  Wochenschr.,"  1891,  Nos.  25,  26. 

4.  Brieger,  O.,  "  Ueber  die  Functionen  des  Magens  bei  Phthisis  pulmonum," 
"Deutsche  med.  Wochenschr.,"  1888,  No.  14. 

5.  Buzelygan  und  Gluczinsky,  "  Ueber  das  Verhalten  des  Magensaftes  bei 
den  verschiedenen  Formen  der  Anamie  und  besonders  der  Chlorose,"  "  Inter- 
nat.  klin.  Rundschau,"  1891,  No.  34. 


400  GASTRIC    DISEASES   AND   THOSE    OF    OTHER    ORGANS. 

6.  Colleville,  "  Progr.  med.,"  1883,  No.  20. 

7.  Destureaux,  "  De  la  Dilatation  du  Coer  Droit  de  I'Origine  Gastrique," 
"  These  de  Paris,"  1879. 

8.  Edinger,  "  Deutsches  Archiv  f.  klin.  Med.,"  1891. 

9.  Einhorn,  Max,  "  N.  Y.  Med.  Record,"  May  4,  1889;  also  "  Berl.  klin. 
Wochenschr.,"  1889,  No.  48. 

10.  Evvald,  "  Neunter  Congress  fiir  innere  Medizin  zu  Wien,"  1890. 

11.  Fenwick,  W.,  "  Ueber  den  Zusammenhang  einiger  krankhafter  Zu- 
stande  des  Magens  mit  anderen  Organerkrankungen,"  "  Virchow's  Archiv," 
1889,  Bd.  cxviii,  S.  187. 

12.  Fenwick,  Samuel,  "  Atrophy  of  the  Stomach,"  London,  1880,  p.  49. 

13.  Fenwick,  loc.  cit. 

14.  Gans,  Edgar,  "  Neunter  Congress  fiir  innere  Medizin,"  Wiesbaden,  1890. 

15.  Glax,  "Ueber  die  Neurosen  des  Magens,"  Wien,  1887,  S.  206. 

16.  Grusdew,  "Wratsch,"  1889,  Nos.  15,  16;  "Centralblatt  fiir  klin.  Med.," 
1892,  S.  92,  Fr. 

17.  Hayem,  "  Des  Alterations  du  chimisme  Stomacal  dans  la  Chlorose," 
"  Bulletin  medec,"  1891,  No.  87. 

18.  Henry  and  Osier,  "Atrophy  of  the  Stomach,  with  Clinical  Features  of 
Progressive  Pernicious  Anemia,"  "  American  Jour,  of  Medical  Sciences," 
April,  1886. 

19.  Herz,  Hans,  "  Storungen  d.  Verdauungsapparates  als  Ursache  u.  Folge 
anderer  Erkrankungen  "  (Berlin,  1898),  Exhaustive  Literature,  pp.  525  to  543. 

20.  Hildebrand,  H.,  "  Deutsch.  med.  Wochenschr.,"  1889,  No.  15. 

21.  Huchard,  "  Maladies  du  Coeur." 

22.  Hiifler,  "  Ueber  die  Functionen  des  Magens  bei  Herzfehlern,"  "  Miinch. 
med.  Wochenschr.,"  1889,  No.  33, 

23.  Hutchinson,  "The  Morbid  States  of  the  Stomach  and  Duodenum," 
London,  1878. 

24.  lUoway,  "Cardiac  Disturb,  from  Gastric  Irritat.,"  "  N.  Y.  Med.  Jour.," 
April,  1897. 

25.  Immermann,  "  Verhandlungen  des  Congresses  fiir  innere  Medizin," 
Wiesbaden,  1889. 

26.  Jones,  Hadfield,  "  Diseases  of  the  Stomach." 

27.  Jones,  Allen  A.,  "  N.  Y,  Med.  Jour.,"  January  19,  1895. 

28.  Klemperer,  "Ueber  die  Dyspepsie  der  Phthisiker,"  "Berlin,  klin. 
Wochenschr.,"  1889,  No.  11. 

29.  Leube,  "  Beitrage  zur  Diagnostik  der  Magenkrankheiten,"  "Deutsches 
Archiv  fiir  klin,  Med.,"  Bd.  xxxill. 

30.  Marfan,  B.,  "Troubles  et  Lesions  Gastriques  dans  la  Phthisie  Pulmo- 
naire,"  Paris,  1887. 

31.  Pick,  "  Therapie  der  Chlorose,"  "Wiener  Med.  Wochenschr.,"  1891, 
No.  50. 

32.  Pidoux,  "  Rapport  de  I'herpetisme  et  des  dyspepsies,"  L'Union  med.," 
1886,  No.  I. 

33.  Potain,  "  Congr6s  de  I'Association  Fran<paise,"  Paris,  1878. 

34.  Rosenstein,  "  Ueber  das  Verhalten  des  Magensaftes  und  Magens  bei 
Diabetes  mellitus,"  "  Neunter  Congress  fiir  innere  Medizin,"  Wien,  1890. 

35.  Rosenthal,  C,  "  Ueber  das  Labferment,"  "  Berliner  klin.  Wochen- 
schr.," 1888,  No.  45. 


EXAMINATION    OF    THE    BLOOD    IN    STOMACH   DISEASES.  4OI 

36.  Schetty,  loc.  cit.,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  XLiv,  S.  219. 

37.  See,  G.,  "  Du  Diagnostik,  etc.,  des  Malad.  du  Cceur." 

38.  Werner,  G.,  "  Gastrische  Krisen  als  Initialsymptom  einer  Tabes  dor- 
salis,"  "Inaug.  Dissert.,"  Berlin,  1889. 

39.  Yeo,  Burney,  "On  the  Treatment  of  the  Gouty  Constitution,"  "British 
Med.  Journal,"  January  7  and  14,  1888. 


CHAPTER  IX. 
THE  BLOOD  AND  URINE  IN  STOMACH   DISEASES.* 

In  general  we  may  say  that,  while  we  are  unable  to  make,  in  any 
given  case,  the  diagnosis  of  stomach  disease  from  an  examination 
of  the  blood  alone,  it  will,  in  many  instances,  render  great  assistance 
in  connection  with  other  symptoms. 

The  presence  of  an  oligocythemia  is  found,  in  cases  of  long-con- 
tinued stomach  disturbances,  serious  enough  in  character  to  interfere 
with  the  nutrition  of  the  body.  For  example,  in  chronic  gastritis 
there  is  always  a  moderate  degree  of  oligocythemia,  the  decrease 
in  the  number  of  red  corpuscles  running  nearly  parallel  with  the 
disturbance  of  nutrition. 

In  the  severe  forms  of  atrophic  gastritis  the  decrease  is  some- 
times enormous ;  so  much  so  that  many  of  these  cases  are  considered 
as  cases  of  primary  pernicious  anemia,  the  true  cause  not  being 
discovered  until  the  postmortem  examination  is  made. 

In  cancer  of  the  stomach  the  oligocythemia  is  usually  marked, 
in  cases  of  well-developed  cachexia  the  number  of  red  corpuscles 
often  being  found  to  be  between  one  and  two  million,  in  some  in- 
stances falling  below  one  million. 

In  ulcer  of  the  stomach  quite  variable  conditions  may  be  found. 
In  cases  of  chronic  ulcer  of  the  stomach  with  slight  hemorrhages, 
the  blood  changes  may  be  those  of  a  simple  secondary  anemia,  or 
the  blood  may  approach  the  normal  in  its  proportions.  In  acute 
or  subacute  ulcer  of  the  stomach  the  blood  may  show  a  normal 
number  of  corpuscles,  unless  there  has  been  a  recent  hemorrhage  of 
considerable  severity.     In  case  of  hemorrhage,  the  decrease  in  the 


*For  the  articles  on  "  The  Condition  of  the  Blood  and  Urine  in  Stomach  Diseases  " 
and  on  "  The  Stomach  Gases  "  the  author  is  indebted  to  Dr.  E.  L.  Whitney. 


402  THE    BIvOOD   AND   URINE    IN    STOMACH   DISEASES. 

number  of  red  corpuscles  is  in  proportion  to  the  amount  of  blood 
lost. 

In  simple  or  benign  dilatation  of  the  stomach  the  anemia  is  pro- 
portional to  the  disturbance  of  nutrition  which  it  produces. 

Leukocytosis. — Considerable  may  be  learned  from  a  study  of 
the  occurrence  and  degree  of  leukocytosis  in  stomach  diseases. 

Under  normal  conditions  a  moderate  degree  of  leukocytosis  (10,000 
to  15,000)  develops  after  meals,  depending  upon  the  absorption  of 
proteid  materials  from  the  gastro-intestinal  tract.  This  does  not 
take  place  in  the  majority  of  cases  of  cancer  of  the  stomach,  but 
does  occur  in  ulcer  of  the  stomach — a  fact  of  considerable  diagnostic 
importance. 

There  is  usually  present  in  cancer  of  the  stomach,  as  in  malignant 
disease  in  other  situations,  a  constant  increase  in  the  number  of 
white  corpuscles,  varying  from  10,000  to  50,000,  the  normal  number 
being  taken  as  about  7000  leukocytes. 

In  the  acute  inflammatory  diseases  of  the  stomach,  such  as  any 
of  the  forms  of  acute  gastritis,  there  is  present  leukocytosis  of  vary- 
ing intensity.  This  is  an  important  fact  to  remember  in  making*  a 
diagnosis  between  acute  gastritis  and  typhoid  fever  in  its  early 
stages, — acute  gastritis  being  accompanied  by  a  moderate  leukocy- 
tosis, typhoid  fever  showing  a  normal  or  decreased  number  of  leuko- 
cytes. 

After  severe  hemorrhage  from  a  gastric  ulcer,  gastric  cancer,  or 
from  varices  in  the  esophagus  or  stomach,  as  from  any  loss  of  blood, 
the  so-called  "posthemorrhagic  leukocytosis"  occurs — a  fact  which 
should  be  taken  into  account  in  forming  any  conclusions  from  leuko- 
cytosis in  the  course  of  gastric  diseases.  This  leukocytosis,  as  a 
rule,  disappears  in  about  three  or  four  days,  and  can  thus  be  ex- 
cluded by  frequently  repeating  the  examination. 

Red  Corpuscles. — In  cancer  of  the  stomach  in  its  later  stages,  the 
red  corpuscles  frequently  show  the  changes  in  form  known  as  poikilo- 
cytosis,  in  an  exquisite  manner.  In  cases  of  severe  anemia  of  any 
kind,  poikilocytosis  may  occur,  but  in  pernicious  anemia  and  cancer 
this  change  is  most  pronounced. 

Hemoglobin. — In  the  various  anemic  states  depending  upon  dis- 
ease of  the  stomach  the  hemoglobin  is  decreased. 

In  ulcer  of  the  stomach  it  is  a  common  observation  to  find  a  normal 
or  only  slightly  decreased  number  of  red  corpuscles  with  a  considera- 
ble decrease  in  the  amount  of  hemoglobin,  the  so-called  "chlorotic 


ALIC\UNITY   OF    THE    BLOOD    IX    STOMACH    DISEASES.  403 

blood."     After  hemorrhages,  especially  when  severe,  the  number  of 
red  corpuscles  may  in  a  short  time  decrease  considerably. 

In  cancer  of  the  stomach  in  its  early  stages  the  blood  may  present 
a  similar  picture ;  bdt  in  the  later  stages  the  number  of  corpuscles  is 
decreased  extremely,  the  hemoglobin  not  being  diminished  propor- 
tionally. 

In  other  diseases  of  the  stomach  the  alterations  are  usually  those  of 
secondary  anemia,  the  red  corpuscles  and  hemoglobin  being  reduced 
in  a  corresponding  ratio. 

Stained  specimens  of  blood  from  patients  suffering  from  the  can- 
cerous cachexia  in  a  severe  form  will  usually  show  the  presence  of  a 
considerable  number  of  normal-sized  nucleated  red  corpuscles,  as  well 
as  megaloblasts,  the  latter  being  much  in  the  minority,  a  point  which 
may  be  of  importance  in  the  diagnosis  of  severe  cancerous  cachexia 
from  primary  pernicious  anemia. 

After  severe  hemorrhages  from  gastric  ulcer,  fairly  numerous 
normoblasts  may  be  found,  in  addition  to  a  decrease  in  the  number  of 
red  corpuscles,  and  in  the  amount  of  hemoglobin.  These  changes 
may  be  of  importance  in  the  diagnosis  of  true  gastric  hemorrhage 
from  the  attempts  at  deception  made  by  mahngerers  and  hysterical 
patients. 

In  chronic  atrophic  gastritis  the  blood  may  show  the  exact  picture 
of  a  primary  pernicious  anemia— viz.,  marked  oHgocythemia,  increase 
in  color  index,  decrease  in  specific  gravity,  presence  of  nucleated  red 
corpuscles,  normoblasts,  microblasts,  and  megaloblasts,  with  a  de- 
crease in  the  number  of  white  corpuscles.  In  by  far  the  larger  number 
of  cases,  however,  the  blood  changes  are  simply  those  of  a  severe 
secondary  anemia. 

Alkalinity  of  the  Blood.— The  researches  of  Loewy  concerning 
the  alkalinity  of  the  blood  in  health  and  disease,  by  the  method  which 
he  has  devised,  have  shown  the  sources  of  error  in  the  methods  form- 
erly in  use,  and  rendered  a  revision  of  our  opinions  necessar3^  The 
method  is  one  which  will  probably  supersede  all  others  for  the  clinical 
laboratory,  on  account  of  simplicity  of  execution  and  accuracy.  At 
present  there  are  not  enough  observations  recorded  to  permit  us  to 
speak  of  its  application  in  diagnosis.  In  the  observations  made  with 
reference  to  digestion  it  has  been  shown  that  a  rich  secretion  of  HCl 
by  the  stomach  increases  the  alkahnity  of  the  blood,  and  vice  versa. 
Whether  this  fact  can  be  of  utility  in  the  study  of  gastric  diseases 
must  remain  at  present  undecided. 


404  THE    BLOOD   AND    URINE    IN   STOMACH    DISEASES. 

In  addition  to  the  examination  of  the  blood  for  the  preceding  con- 
stituents, it  may  be  of  importance  in  cases  of  continued  fever  with 
marked  gastric  symptoms,  in  which  the  diagnosis  hes  between  some 
severe  inflammatory  disease  of  the  stomach  and  typhoid  fever,  to 
make  a  trial  of  the  ^^''idal  test  for  typhoid. 

This  test  is  of  no  value  in  the  early  days  of  the  disease,  the  reaction 
seldom  appearing  before  the  seventh  day,  and  rarely  on  the  fifth  or 
sixth  day. 

The  results  of  our  knowledge  of  the  blood  changes  in  the  A^arious 
stomach  diseases  may  be  summed  up  as  follows : 

Actite  Gastritis. — Usually  a  slight  degree  of  leukocytosis,  increasing 
with  the  intensity  of  the  inflammation. 

Chronic  Gastritis. — A  decrease  in  the  number  of  red  corpuscles  and 
hemoglobin,  the  leukocytes  showing  normal  numbers,  as  a  rule. 

Chronic  Atrophic  Gastritis. — The  blood  ma}^  show  the  same  changes 
as  in  the  simple  chronic  gastritis,  or  may  show  the  blood  changes  of 
pernicious  anemia:  poikilocytosis,  marked  decrease  of  red  corpus- 
cles, a  marked  decrease  in  hemoglobin,  the  decrease  being  less  in  pro- 
portion than  that  of  the  red  corpuscles,  a  decrease  in  the  number  of 
leukocytes,  and  the  presence  of  a  large  number  of  nucleated  red  cor- 
puscles, normoblasts,  megaloblasts,  and  microblasts. 

Gastric  Ulcer. — In  the  old  chronic  forms  of  ulceration  the  blood 
usually  shows  the  changes  of  a  secondan,"  anemia,  as  in  chronic  gas- 
tritis. 

In  ulcers  of  recent  origin  the  blood  may  show  no  variations  from  the 
normal,  or  it  may  show  the  characteristic  changes  of  chlorosis — viz., 
nearly  a  normal  number  of  red  corpuscles  with  a  considerable  decrease 
in  the  percentage  of  hemoglobin. 

After  hemorrhages,  the  changes  are  those  common  to  loss  of  blood 
from  any  part  of  the  body — a  decrease  in  the  red  corpuscles  and 
hemoglobin,  an  increase  of  the  leukocytes  for  a  few  days,  and  the 
presence  of  normoblasts  in  the  blood. 

In  ulcer  digestion  leukocytosis  occurs,  a  point  of  some  value  in  the 
differential  diagnosis  between  ulcer  and  cancer. 

Cancer  of  the  Stomach. — In  the  early  stages  the  changes  may  be 
simply  those  of  secondary  anemia.  In  the  later  stages,  when  the 
cachexia  becomes  apparent,  the  blood  changes  are  rather  character- 
istic. There  is  a  marked  decrease  in  the  number  of  red  corpuscles 
and  in  the  amount  of  hemoglobin,  the  former  being  often  between  one 
and  two  million,  the  latter  from  twenty  to  thirty  per  cent.     There 


THE   GASES   OE   THE   STOMACH.  405 

are  often  a  number  of  nucleated  red  corpuscles,  both  normoblasts  and 
megaloblasts.  The  red  corpuscles  may  show  variations  in  size, 
averaging  smaller  than  normal,  often  with  an  exquisite  poikilocytosis. 
A  leukocytosis  is  usually  present,  varying  greatly  in  its  intensity. 
There  is,  with  rare  exceptions,  no  digestion  leukocytosis.  T.  P. 
Henry  inclines  to  the  opinion  that  the  reduction  of  red  corpuscles  in 
gastric  carcinoma  is  not  proportionate  to  the  cachexia,  while  in  per- 
nicious anemia  the  cachexia  does  not  keep  step  with  the  oliogocythe- 
mia.  The  number  of  red  corpuscles  is  rarely  below  2,000,000  in  can- 
cer, while  in  pernicious  anemia  it  is  often  below  this,  and  he  believes 
this  to  be  a  diagnostic  differentiation  ("Arch.  f.  Verdauungskrank.," 
Bd.  IV,  Heft  I). 

In  dilatation  of  the  stomach  from  benign  causes,  the  changes  are 
simply  those  of  secondary  anemia,  the  alterations  being  proportional 
to  the  disturbances  of  nutrition. 

THE  GASES  OF  THE  STOMACH. 

Under  normal  conditions  the  stomach  contains  a  mixture  of  gases, 
derived  in  part  from  air  swallowed  with  the  food,  in  part  from  chemi- 
cal and  fermentative  processes  in  the  stomach,  and  possibly  from  a 
small  amount  of  CO2  eliminated  from  the  blood  flowing  through  the 
gastric  mucosa.  The  contents  of  a  normal  stomach,  removed  at  the 
height  of  digestion,  and  placed  in  a  fermentation  tube  at  the  body 
temperature,  exhibit  for  several  days  only  slight  gas  formation, 
this  occurring  only  when  the  free  HCl  has  been  nearly  or  completely 
neutralized  by  the  food  products.  After  this,  fermentation  and 
putrefaction  proceed  as  usual  in  fluids  rich  in  proteid  and  carbohy- 
drate material. 

Under  pathological  conditions,  such  as  marked  dilatations  with 
stenosis,  especially  when  due  to  malignant  disease,  the  case  is  altered. 
The  food,  which  usually  contains  a  variable  number  of  bacteria,  is  not 
properly  sterilized  in  the  stomach  on  account  of  the  partial  deficiency 
or  absence  of  HCl,  and  it  remains  for  a  long  time  in  the  stomach ;  in 
addition,  it  is  not  subjected  to  a  normal  peristalsis.  The  requisite 
conditions  for  an  abundant  bacterial  grovv^th  are  thus  present — viz., 
an  animal  fluid  (containing  both  carbohydrates  and  animal  proteids), 
heat,  and  moisture. 

Various  gases  have  been  found  in  the  stomach  in  such  conditions, 
among  which  may  be  named  acetylene,  hydrogen,  carbon  dioxid, 
nitrogen,  oxygen,  marsh  gas  (CH4),  and  sulphuretted  hydrogen. 


4o6  THE    BLOOD    AND    URINE)    IX    STOMACH    DISEASES. 

The  question  of  the  special  variety  of  gas  is  not  of  so  much  im- 
portance as  that  of  the  formation  of  any  gas.  Accurate  gas  analyses 
have,  up  to  the  present  time,  yielded  little  of  diagnostic  value,  and 
from  their  difl&culty  will  seldom  be  attempted  by  the  general  practi- 
tioner. 

The  presence  of  combustible  gases  in  dilated  stomachs  was  first 
demonstrated  by  G.  Hoppe-Seyler  ("A^erhandl.  d.  Congr.  f.  innere 
Medizin,"  1892,  S.  392)  and  F.  Kuhn  ("Zeitschr.  f.  Med.,"  Bd.  xxi, 
S.  572).  These  investigators  demonstrated  that  h^^drogen,  marsh 
gas,  etc.,  could  be  formed  notwithstanding  the  presence  of  a  consid- 
erable amount  of  free  HCl.  The  influence  of  various  antiseptic 
agents  on  the  process  of  gas  formation  in  the  stomach  has  been  care- 
fully investigated  by  F.  Kuhn,  whose  results  constitute  an  important 
practical  contribution  to  the  therapy  of  gastrectasia. 

To  test  for  the  presence  and  amount  of  gas  formation,  the  freshly 
drawn  stomach  contents  are  well  mixed  and  broken  up  into  a  finely 
divided  state,  poured  into  a  fermentation  tube  (that  devised  by  Ein- 
horn  for  the  estimation  of  sugar  in  urine,  or  the  ureometer  of  Dore- 
mus  mav  be  used),  and  the  tube  (loosely  stoppered  with  cotton) 
placed  in  a  warm  oven  at  the  temperature  of  the  body.  If  none  of 
these  is  at  hand,  a  fair  substitute  may  be  improvised  by  filhng  a  large 
test-tube  with  the  stomach  contents  and  inverting  over  a  small 
beaker  partially  filled  with  the  same  material,  allowing  the  lower  end 
of  the  test-tube  to  dip  into  the  stomach  contents  in  the  beaker,  to 
retain  the  fluid  in  the  tube  by  atmospheric  pressure. 

If  evolution  of  gas  takes  place  within  a  few  hours,  the  presump- 
tion is  that  we  have  to  deal  with  a  case  of  stenosis  of  the  pylorus ;  and 
if,  at  the  same  time,  we  find  a  marked  formation  of  lactic  acid  and  an 
absence  of  HCl,  we  may  assume  that  it  is  a  case  of  malignant  stenosis 
of  the  pylorus  with  a  high  degree  of  dilatation. 

In  non-malignant  stenosis  we  find,  as  a  rule,  that  the  gas  formation 
goes  on  rather  less  rapidly  and  is  not  associated  with  an  excess  of 
lactic  acid  as  in  malignant  stenosis. 

In  dilatation  unaccompanied  by  stenosis,  and  even  in  the  presence 
of  small  quantities  of  free  HCl,  we  find  that  gas  is  formed;  often, 
however,  only  after  the  tube  has  been  allowed  to  stand  for  several 
days. 

The  gas  may  be  submitted  to  various  tests  to  determine  its 
character. 

A  few  c.c.  of  a  strong  solution  of  caustic  soda  are  placed  in  the  lower 


URINARY    CHANGES    IN    STOMACH    DISEASES.  407 

part  of  the  fermentation  tube  and  allowed  to  stand  for  some  time. 
If  the  gas  is  composed  partly  or  wholly  of  CO2,  it  will  be  absorbed 
by  the  alkali,  and  its  volume  percentage  may  be  read  off  directly  by 
the  decrease  in  volume  of  the  gas. 

A  small  amount  of  the  gas  is  allowed  to  bubble  out,  and  a  piece  of 
filter-paper,  previously  dipped  in  a  solution  of  lead  acetate,  is  held  in 
the  gas  as  it  escapes.  If  any  sulphuretted  hydrogen  is  present,  the 
paper  will  turn  black,  due  to  the  formation  of  lead  sulphid. 

A  portion  of  the  gas  may  be  tested  for  inflammability  by  allowing 
it  to  flow  out  as  before,  and  attempting  ignition  by  holding  a  lighted 
match  to  it  as  it  escapes.  If  it  take  fire  or  give  a  slight  explosion, 
the  probabilities  are  that  hydrogen,  marsh  gas,  or  acetylene  are 
present. 


URINARY  CHANGES  IN  STOMACH  DISEASES. 

While  many  interesting  and  valuable  observations  upon  the  urin- 
ary alterations  in  stomach  diseases  have  been  made,  it  must  be  stated 
that,  up  to  the  present,  little  of  diagnostic  importance  has  been  deter- 
mined. It  is  not  without  interest,  however,  to  take  a  short  review  of 
the  topics  so  far  as  it  concerns  the  subject  of  this  book. 

The  Amount. — So  long  as  appetite,  digestion,  and  absorption 
from  the  stomach  and  intestinal  tract  are  little  interfered  with,  there 
are  only  trifling  alterations  in  the  quantity  of  urine. 

The  quantity  of  urine  sinks  in  cases  of  vomiting :  as,  for  example,  in 
acute  gastritis  and  gastric  ulcer,  the  decrease  in  the  amount  of  urine 
being  in  an  almost  exact  ratio  to  the  amount  of  fluid  lost  by  vomiting. 

It  is,  however,  in  marked  cases  of  gastric  dilatation  and  pyloric 
stenosis  that  the  greater  decrease  in  the  amount  of  urine  is  noticed. 
In  well-marked  cases  of  dilatation  the  amount  of  urine  often  sinks 
to  from  300  to  500  c.c.  Under  these  conditions  a  continued  low  quan- 
tity is  an  unfavorable  prognostic  sign,  while  an  increase  indicates  an 
improvement  in  the  motor  function. 

The  specific  gravity  has  little  diagnostic  significance,  but,  in  gen- 
eral, has  about  the  same  value  as  the  amount  of  urine.  In  cases  of 
dilatation,  in  which  the  element  of  inanition  is  beginning  to  be  a  factor 
in  the  clinical  picture,  we  find  that  the  solids  of  the  urine,  as  indicated 
by  the  specific  gravity,  fall;  while  in  cases  in  which  the  nutrition  is 
well  preserved,  the  total  solids  of  the  urine  approximate  the  normal 
value. 

27 


408  THE    BLOOD   AND    URINE    IN    STOMACH    DISEASES. 

The  Reaction. — Bence  Jones,  in  1819,  first  explained  the  well- 
known  relation  existing  between  the  secretion  of  gastric  juice  and  the 
reaction  of  the  urine.  After  a  meal  the  acidity  of  the  urine  decreases, 
often  becoming  neutral  or  amphoteric,  and,  occasionall)^  alkaline  in 
from  three  to  five  hours.  Subsequently,  the  acidity  of  the  urine  in- 
creases, reaching  about  the  average  a  short  time  after  the  food  has 
been  propelled  from  the  stomach  into  the  intestines.  The  range  of 
variation  is  greater  following  a  full  meal  than  a  light  repast,  so  that  a 
greater  fall  in  the  acidity  is  found  after  dinner  than  after  either  of  the 
other  meals. 

This  phenomenon  Bence  Jones  explained  upon  the  ground  of  a 
greater  alkalinity  of  the  blood,  as  a  consequence  of  abstraction  from 
it  of  acids  or  acid-forming  substances.  The  presence  of  an  increased 
alkalinity  of  the  blood  leads  to  increased  excretion  of  alkalies  in  the 
urine  and  a  diminished  acidity.  An  additional  factor  may  be  the 
presence  of  alkalies  or  of  alkaline  carbonates  in  the  food,  which  neu- 
tralize the  acidity  of  the  gastric  juice,  and  assist  also,  after  absorp- 
tion, in  increasing  the  alkalinity  of  the  blood. 

From  these  physiological  facts  the  variations  of  the  reaction  in  dis- 
ease are  easily  understood.  In  the  vomiting  of  ulcer,  if  profuse,  a 
large  amount  of  acid  is  withdrawn  from  the  system;  and,  in  some 
cases,  the  urine  may  exhibit  for  some  time  a  neutral,  or  even  alkaline, 
reaction.  In  cases  of  hyperacidity  of  the  gastric  juice  in  which  a 
larger  quantity  of  acid  than  normal  is  withdrawn  from  the  blood,  the 
curve  of  urinary  acidity  undergoes  greater  variation  than  under  nor- 
mal conditions.  In  cases  in  which  there  is  a  considerable  diminution, 
or  a  total  absence  of  the  acid  secretion  of  the  stomach,  this  variation 
in  the  reaction  of  the  urine  does  not  occur,  or  if  any  variation  does 
take  place,  it  is  less  marked  than  under  normal  conditions.  Hence  it 
will  be  seen  that  in  cases  of  atrophic  gastritis,  severe  chronic  gastritis, 
and  in  carcinoma  of  the  stomach,  with  an  absence  of  HCl,  little  or  no 
variation  in  the  acidity  of  the  urine  occurs,  a  fact  that  may  be  of  some 
importance  in  the  differential  diagnosis  between  carcinoma  and  ulcer 
of  the  stomach,  especially  when  the  occurrence  of  hematemesis  or 
bloody  stools  contraindicates  the  use  of  the  stomach-tube. 

The  Chlorids. — The  amount  of  chlorin  depends  primarily  upon 
the  amount  of  food,  and,  with  it,  on  the  amount  of  chlorids  absorbed 
from  the  stomach.  The  amount  of  chlorids  present  in  the  urine  is  alsa 
in  an  inverse  ratio  to  the  amount  of  HCl  secreted  by  the  stomach. 

In  ulcer  of  the  stomach,  associated  with  considerable  vomiting  of  a 


EXCRl^TION    OF    PHOSPHATES    IN    GASTRIC    DISEASES.  409 

large  amount  of  highly  acid  gastric  juice,  a  considerable  decrease  in 
the  amount  of  urinary  chlorids  will  be  found,  as  also  in  other  cases  of 
vomiting  in  which  a  large  amount  of  HCl  is  lost. 

In  hyperacidity  without  vomiting,  the  amount  of  urinary  chlorids 
decreases  as  secretion  goes  on,  diminishing  in  well-marked  cases  to  a 
very  low  percentage,  increasing  again  as  absorption  from  the  stomach 
and  intestine  goes  on,  finally  reaching  the  highest  part  of  the  chlorid 
curve  five  or  six  hours  (sometimes  later)  after  the  ingestion  of  the 
meal. 

In  cases  of  anacidity  this  curve  of  urinary  chlorids  does  not  occur, 
no  fall  of  chlorids  occurring  after  the  meal,  a  slight  increase  taking 
place  as  the  absorption  of  the  food  goes  on. 

In  severe  cases  of  gastrectasia  with  pyloric  stenosis,  the  amount  of 
chlorids  in  the  urine  sinks  very  considerably,  the  decrease  being  in 
proportion  to  the  severity  of  the  affection.  An  increase  in  the  amount 
of  chlorids  without  a  corresponding  change  in  the  diet  may  be  taken 
as  a  symptom  of  improvement,  in  this  respect  being  even  of  more 
prognostic  importance  than  the  increase  in  the  amount  of  urine 
which  usually  occurs  at  the  same  time. 

Taken  in  connection  with  the  total  nitrogen  of  the  urine,  the  amount 
of  chlorids  may  be  of  assistance  in  determining  the  question  of  a 
benign  or  malignant  stenosis  of  the  pylorus. 

If  one  finds,  for  example,  in  the  urine  a  small  amount  of  chlorids 
and  a  proportionally  small  amount  of  nitrogen,  it  speaks  for  a  simple 
inanition,  a  benign  stenosis ;  but  if,  on  the  other  hand,  one  finds  a 
srnall  amount  of  chlorids  and  a  relatively  large  amount  of  nitrogen, 
it  speaks  for  the  presence  of  a  malignant  stenosis. 

The  Phosphates. — The  investigation  of  the  excretion  of  phos- 
phates in  stomach  diseases  has  yielded  little  in  the  line  of  diagnosis  as 
yet.  The  deposit  of  basic  phosphates  in  the  freshly  voided  urine 
passed  after  meals  is  quite  frequently  seen  in  cases  of  hyperacidity, 
though  the  same  change  may  also  occur  in  perfectly  healthy  indi- 
viduals. The  deposit  of  the  basic  earthy  phosphates  in  these  cases  is 
due  to  the  alkaline  tide  spoken  of  in  the  paragraph  upon  the  reaction 
of  the  urine. 

In  hyperacidity,  according  to  Robin,  the  excretion  of  phosphoric 
acid  is  considerably  increased. 

According  to  F.  Miiller,  the  excretion  of  phosphates  is  increased  in 
cancer  of  the  stomach,  though  not  in  all  cases. 

Of  more  diagnostic  importance,  however,  is  the  relation  existing 


4IO  THE   BLOOD   AND   URINE   IN   STOMACH   DISEASES. 

between  the  excretion   of  nitrogen   and  phosphoric   acid.     Under 
normal  conditions  the  proportion  is  about  as  follows : 

N     :     P2O5     :    :      loo     :      17  to  20. 

In  malignant  diseases  in  general,  the  proportion  of  P2O5  rises,  in  one 
case  of  gastric  carcinoma  recorded  by  Chas.  E.  Simon  the  relation 
being  loo  :  34. 

The  Sulphates. — Of  the  two  forms  in  which  sulphuric  acid  occurs 
in  the  urine,  the  preformed  sulphates  have  only  a  passing  interest  as 
being  a  measure  of  the  proteid  metabolism  going  on  in  the  system; 
while  the  ethereal  sulphates  have  a  more  direct  bearing,  as  they  seem 
to  be  formed  chiefly  by  putrefactive  changes  within  the  intestine. 
As  a  normal  secretion  of  HCl  and  a  normal  motility  seem  to  be  the 
chief  checks  upon  intestinal  putrefaction,  it  can  be  readily  seen  that 
in  cases  of  sub-  or  anacidity,  especially  when  associated  with  an  im- 
paired motility,  the  putrefactive  changes  in  the  intestine  are  increased 
and  lead  to  an  increased  formation  and  excretion  of  the  ethereal  or 
combined  sulphates. 

In  expressing  an  opinion  as  to  the  condition  of  the  stomach  from 
the  amount  and  proportion  of  the  ethereal  sulphates,  care  must  be 
taken  to  exclude  any  intestinal  or  peritoneal  troubles,  which  would, 
by  themselves,  have  a  tendency  to  increase  the  amount  of  putrefac- 
tion in  the  intestine. 

Under  normal  conditions  the  amount  of  the  total  sulphuric  acid  is 
from  two  to  three  gm.,  increasing  under  a  meat  diet,  decreasing  under 
a  vegetable  diet;  the  amount  of  ethereal  sulphuric  acid  being  from 
two  to  three  decigrams. 

The  average  normal  ratio  between  the  preformed  and  ethereal 
sulphuric  acid  is  as  ten  is  to  one,  the  proportion  being  stated,  as  a  rule, 
as  follows : 

A     :      B     :    :      10     :      I 

In  cases  of  nervous  anacidity  with  periods  of  normal  secretion,  it 
may  assist  in  forming  an  opinion  as  to  the  severity  of  the  case  to  find 
a  normal  ratio  of  the  sulphates.  In  a  case  of  anacidity  due  to  some 
organic  trouble,  the  amount  of  ethereal  sulphates  will,  as  a  rule,  be 
increased,  and  the  ratio,  instead  of  being  one  to  ten,  may  be  increased 
to  a  marked  degree,  in  some  cases  reaching  nearly  equal  amounts. 

Indoxyl-sulphate  of  potassium  has,  for  the  most  part,  the  same 
significance  as  an  excessive  amount  of  ethereal  sulphates  or  an  in- 
crease in  their  ratio. 


UREA   AND    NITROGEN    IN    GASTRIC    DISEASES.  4 II 

This  chromogen  of  the  urine  is  a  product  of  the  putrefactive  bac- 
teria of  the  intestinal  canal.  As  a  result  of  their  action  upon  the  pro- 
teid  bodies  of  the  intestinal  canal,  indol  is  produced,  from  which,  by 
successive  oxidations,  indigo-blue  is  formed.  This,  by  combination 
with  the  elements  of  sulphuric  acid  and  potassium,  forms  the  sub- 
stance, indoxyl-sulphate  of  potassium,  or  indican. 

Quantitative  methods  for  determination  of  the  amount  of  indican 
have  recently  been  published,  but  for  practical  purposes  the  qualita- 
tive color  test  is  sufficient:  5  c.c.  urine  are  mixed  with  5  c.c.  pure 
hydrochloric  acid,  then  3:  c.c.  of  chloroform  are  added,  and  a  small 
drop  of  a  solution  of  calcium  hypochlorite.  Then  the  mixture  is 
shaken ;  the  indigo  formed  from  the  indican  by  oxidation  passes  into 
the  chloroform.  If  the  first  drop  of  hypochlorite  of  calcium  solution 
causes  no  blue  coloring  of  the  chloroform,  a  second  drop  is  added,  and 
so  on  until  the  blue  color  is  no  longer  intensified.  A  strong  coloration 
of  blue,  particularly  if  no  food  has  been  taken  for  six  hours,  signifies 
a  pathological  increase  of  the  percentage  of  indican. 

Owing  to  the  fact  that  certain  species  of  bacteria  may  be  present 
which  do  not  form  indol,  the  absence  or  presence  of  this  body  in  nor- 
mal amounts  in  the  urine  does  not  prove  the  absence  of  putrefactive 
changes  in  the  intestinal  canal. 

Recent  observations  of  Charles  E.  Simon  {loc.  cit.)  show  that  indi- 
can is  present  in  excess  in  the  urine,  in  cases  of  marked  subacidity, 
anacidity,  gastric  carcinoma,  stenosis  of  the  pylorus  from  any  cause, 
and  also  in  cases  of  gastric  ulcer  with  hyperacidity. 

Careful  study  of  a  series  of  cases  of  gastric  diseases  with  relation 
to  the  urine  seems  to  show  that  those  cases  of  gastric  diseases  with 
a  marked  increase  in  the  amount  of  indican,  are  those  which  are  asso- 
ciated with  a  lack  of  motor  power. 

It  must  be  said,  however,  that  the  ratio  of  the  ethereal  to  the  pre- 
formed sulphates  is  a  better  index  to  amount  of  intestinal  putrefac- 
tion. 

Indigo-red,  also  called  urrhodin,  has  essentially  the  same  signifi- 
cance as  indigo-blue  or  indican. 

Urea  and  Nitrogen. — The  nitrogen  eliminated  in  the  urine  may 
come  direct  from  the  food  ingested  or  from  the  nitrogenous  metab- 
olism of  the  body. 

In  general  it  may  be  said  that  those  diseases  which  are  attended 
with  impaired  digestion  of  proteid  foods  are  attended  with  a  decrease 
in  the  amount  of  nitrogen  eliminated  in  the  urine.     In  the  cachexia 


412  THE)   BLOOD   AND    URINE   IN    STOMACH   DISEASES. 

which  results  from  cancer  of  the  stomach,  the  eHmination  of  nitrogen 
is  greater  than  is  the  eHmination  in  simple  inanition  of  the  same  de- 
gree of  severity. 

There  is  at  present  no  explanation  of  this  fact,  unless  it  be  due  to 
some  product  of  the  tumor  itself  which  is  eliminated  by  the  urine,  or 
to  the  increased  metabolism  of  the  body  resulting  from  some  product 
of  the  neoplasm.  This  theory  as  to  the  production  of  some  poisonous 
substance  by  the  tumor  itself  is  supported  by  the  fact  that  even  small 
carcinomata,  situated  in  a  part  of  the  body  where  they  in  no  way 
influence  the  bodily  functions,  give  rise  occasionally  to  an  increase 
in  the  elimination  of  nitrogen  by  the  urine. 

The  proportions  of  the  various  nitrogenous  bodies  in  the  urine, 
according  to  the  few  published  observations,  depart  considerably 
from  the  normal  in  carcinoma.  In  normal  urine  the  nitrogenous 
matter  is  divided  about  as  follows:  Urea,  96  per  cent. ;  uric  acid,  1.8 
per  cent.;  ammonia,  1.2  per  cent.;  and  extractive  matters,  0.6  per 
cent,  to  0.8  per  cent. 

In  cases  of  carcinoma  examined  by  Topfer  the  proportions  were  as 
follows :  Urea  as  low  as  80  per  cent. ;  uric  acid,  one  to  five  per  cent. ; 
ammonia,  0.2  per  cent,  to  13  per  cent.,  and  extractive  matters  13  per 
cent,  to  23  per  cent.  Von  Noorden  also  found  the  ammonia  increased 
(10.2  percent,  to  13.9  percent.). 

It  is  thus  seen  that  in  these  cases  there  is  a  relative  decrease  in  the 
amount  of  urea,  with  or  without  a  rise  in  the  amount  of  uric  acid,  and 
a  considerable  increase  in  the  relative  amounts  of  ammonia  and 
extractives. 

Acetone  and  Diacetic  Acid. — Acetone  and  diacetic  acid  occur 
in  the  urine  in  various  disturbances  of  the  digestive  tract  affecting 
both  the  stomach  and  intestines,  and,  according  to  Torenz,  their  oc- 
currence is  not  infrequent. 

Acetone  occurs  frequently  in  the  digestive  disturbances  of  children, 
and  is  by  some  authors  considered  as  the  cause  of  the  convulsions 
which  so  often  accompany  these  derangements. 

Acetone  is  found  in  the  urine  in  increased  amounts  in  cases  of  inani- 
tion and  in  cachectic  conditions,  and  to  this  fact  ma}"  be  assigned  the 
occurrence  of  acetone  in  increased  amount  in  cases  of  cancer  and  of 
dilatation  of  the  stomach. 

In  general  it  may  be  said  that  the  increase  in  amount  of  acetone 
and  the  presence  of  diacetic  acid  indicate  an  increase  in  albumin  dis- 


THE    DIAZO    REACTION.  4^3 

integration  of  the  tissues.  When  diacetic  acid  is  found,  the  prognosis 
is  always  grave. 

Albumin.— Albumin  is  not  of  infrequent  occurrence  in  cases  of 
gastric  disturbances.  It  may  be  the  result  of  any  severe  stomach 
disease. 

Von  Noorden  found  albumin  with  relative  frequency  after  the  onset 
of  severe  gastric  pains,  such  as  occur  at  intervals  in  ulcer  of  the 
stomach,  and  also  after  profuse  hematemesis.  In  cases  of  cancer  of 
the  stomach,  especially  in  the  later  stages,  albumin  is  found,  either 
regularly  or  temporarily,  in  a  large  proportion  of  cases  (see  section 
on  Relations  of  Renal  to  Gastric  Diseases). 

Peptonuria.— The  question  as  to  the  occurrence  of  peptone  in  the 
urine — as  the  word  peptone  is  now  employed — is   not   definitely 

settled. 

Under  certain  conditions  the  urine  fails  to  react  to  the  ordinary 
tests  for  albumin,  such  as  Heller's  nitric  acid  test,  Purdy's  acetic  acid 
and  potassium  ferrocyanid  test,  and  the  boiling  test;  while  it  cer- 
tainly contains  some  form  of  proteid  which  reacts  to  the  biuret  test. 

The  question  whether  this  is  a  secondary  albumose,  pure  peptone, 
or  a  mixture  of  the  two,  is  of  minor  importance  from  a  clinical  stand- 
point. Recent  investigations  show  that,  in  the  course  of  absorption, 
peptones  are  acted  upon  by  the  epithelium  of  the  gastro-intestinal 
tract  and  reconverted  into  the  coagulable  proteids. 

This  theory  renders  the  occurrence  of  peptonuria  in  the  course  of 
gastric  ulcer,  carcinoma  of  the  stomach,  erosions  of  the  mucosa,  and 
ulceration  of  the  intestine  easy  of  comprehension.  The  occurrence 
of  these  bodies  in  such  diseases  is  general  in  this  class  of  cases,  though 
many  observers  have  failed  to  demonstrate  them  in  all  cases. 

Ferments. — Under  normal  conditions  the  urine  contains  a  variable 
quantity  of  pepsin  and  rennin  ferment.  The  maximum  excretion  of 
pepsin  is  found  from  four  to  six  hours  after  meals.  Pepsin  is  often 
found  to  be  decreased  or  entirely  absent  in  the  urine  in  cases  of  cancer 
of  the  stomach,  and  would  probably  be  found,  in  the  course  of  ex- 
tended observations,  to  vary  in  an  exact  ratio  to  the  amount  of  pep- 
sin formed  by  the  stomach. 

Rennin  is  found  to  undergo  the  same  variations  as  pepsin,  and  its 
variations  have  the  same  clinical  significance. 

Ehrlich's  Diazo  Reaction.— The  presence  or  absence  of  this  color 
reaction  of  the  urine  was  formerly  thought  to  be  of  great  diagnostic 
importance  for  the  recognition  and  differentiation  of  typhoid  fever. 


414  the;  bi^ood  and  urine  in  stomach  diseases. 

In  tlie  two  diseases  of  the  stomach  (acute  and  phlegmonous  gastritis) 
with  which,  in  its  earher  stages,  typhoid  fever  might  be  confounded, 
it  would  be  of  great  value  were  its  accuracy  undoubted.  Quite  an 
extended  experience  with  this  test,  used  on  all  patients  entering  the 
hospital  for  several  months,  showed  conclusivel}^  that  it  could  not  be 
relied  upon  as  a  differential  test,  several  patients  giving  a  typical 
reaction  whose  history  before,  during,  and  after  the  examination 
excluded  typhoid  absolutely.  On  the  other  hand,  even  in  typhoid 
fever  the  reaction  frequently  is  absent,  so  that  any  absolute  deduc- 
tions as  to  the  disease  from  this  reaction  are  apt  to  be  misleading. 
Von  Jaksch  looks  upon  the  reaction  as  merely  a  poor  test  for  acetone. 


PART    THIRD. 

THE   GASTRIC   CLINIC. 


CHAPTER  I. 
ACUTE    GASTRITIS. 

Simple  Acute  Gastritis. — Phlegmonous  or  Purulent  Gastritis. — Sup- 
purative Inflammation  of  the  Gastric  Mucosa. — Abscess  of  the 
Stomach. — Infectious  Gastritis. — Gastritis  Mycotica  or 
Parasitaria. — Gastritis    Diphtherica    and    Crou- 
posa. — Toxic  Gastritis. — Gastritis  Venenata. 

Gastritis  is  a  collective  or  generic  term  which  comprehends  all 
inflammatory  processes  of  the  stomach  proper,  including  the  so-called 
catarrh  of  the  superficial  layer  of  columnar  epithelium,  the  inflamma- 
tion of  the  glandular  parenchyma  and  interstitial  connective  tissue, 
the  purulent  infiltration  of  the  submucosa  and  muscularis,  and  also 
the  penetrating  excoriations  of  corrosive  poisons. 

It  is  natural  that  these  manifold  morbid  conditions  should  present 
considerable  variations  in  etiology  as  well  as  in  the  intensity  of  the 
symptoms.  It  is  almost  impossible  to  draw  a  sharp  limit  separating 
the  simple  superficial  catarrhs  from  the  deeper,  penetrating  inflamma- 
tions.    Penzoldt  suggests  the  line  between  mucosa  and  submucosa. 

We  may  designate  as  simple  gastritis  that  inflammation  of  the  gas- 
tric mucosa  which  involves  not  only  the  superficial  columnar  epithe- 
lium, but,  as  a  rule,  the  glandular  parenchyma.  This  condition  may 
occur  in  an  acute  and  in  a  chronic  form,  and  under  each  classification 
— the  acute  and  the  chronic  gastritis — one  may  arrange  two  subdivi- 
sions: (i)  the  primary  and  (2)  the  secondary  gastritis. 

We  therefore  have  (i)  the  acute,  simple,  primary  gastritis,  which 
occurs  as  the  original  disease;  and  (2)  the  acute  secondary  gastritis 
known  as  the  gastritis  sympathica  acuta,  which  occurs  not  as  the 

415 


41 6  acute;  gastritis. 

original  disease,  but  as  a  frequent  accompaniment  of  numerous  acute 
febrile  disorders.  All  the  exanthematous  infectious  diseases — mea- 
sles, scarlatina,  variola,  typhus  and  typhoid  fevers,  puerperal  fever, 
pyemia,  dysenterv',  croup,  and  diphtheria — are  known  to  effect  path- 
ological changes  in  the  gastric  mucosa  directly,  or  to  influence  it  detri- 
mentally by  reflex  nervous  action  (Hoppe-Seyler,  "Allgemeine 
Biologic,"  1877,  p.  242). 

There  is  a  very  plausible  desire  evident  in  some  recent  works  on  the 
subject  to  avoid  the  name  stomach  or  gastric  catarrh,  because  the  word 
catarrh  has  reference  to  a  superficial  inflammation,  but  in  gastritis  we 
are  dealing  also  with  parencyhmatous  inflammation.  Penzoldt  uses 
the  expression  "simple  gastritis"  for  an  inflammation  reaching  no 
deeper  than  the  submucosa  (gastritis  simplex) ;  for  the  penetrating 
results  of  suppurative  or  purulent  inflammation  he  uses  the  term 
"grave  gastritis"  (gastritis  gravis).  He  does  not  favor  the  terms 
"toxic"  and  "infective  gastritis,"  for  to  a  certain  extent  all  forms  of 
this  disease  are  toxic  and  infective,  and  in  his  book,  "Specielle  Thera- 
pieinnerer  Krankheiten, "  vol.  iv,  page  320,  he  discusses  only  (i)  sim- 
ple and  grave  acute  gastritis,  (2)  chronic  gastritis,  and  (3)  purulent  or 
suppurative  gastritis.  Fleischer  ("Specielle  Therap.  u.  Pathol,  d. 
Magen-  u.  Darmkr.,"  S.  793)  describes  (i)  simple  acute,  (2)  secondary 
or  sympathetic  acute,  (3)  phlegmonous  or  purulent,  (4)  toxic,  (5) 
diphtheric,  croupous,  mycotic,  parasitic,  (6).  chronic  gastritis.  Ex- 
cepting those  forms  mentioned  by  Fleischer  under  group  5,  Boas  de- 
scribes all  of  these  in  separate  chapters. 

Bwald  mentions  and  describes  all  of  these  forms,  and  subdivides 
the  suppurative  inflammation  (the  gastritis  phlegmonosa  purulenta) 
into  an  idiopathic  primarj^  and  a  metastatic  secondary  form.  Sydney 
Martin's  treatise  on  "The  Organic  and  Functional  Diseases  of  the 
Stomach"  deals  with  the  symptomatology,  pathology,  and  treatment 
of  acute  and  chronic  gastritis  in  one  chapter  (Chap,  viii),  and  then 
goes  on  to  speak  of  toxic  and  infective  gastritis  in  the  next  chapter 
(Chap.  ix).  Albert  Mathieu  ("Therapeutique  des  Maladies  de  I'es- 
tomac,"  3me  Edition,  Paris,  1898)  briefly  mentions  acute,  chronic, 
and  atrophic  gastritis,  and  the  varying  amount  of  mucus  and  acid 
accompanying  these  diseases ;  none  of  the  other  forms  are  referred  to. 

Rosenheim  ("Pathol,  u.  Therap.  d.  Krankh.  des  Verdauungs- 
apparates,"  p.  99)  describes  gastritis  as  acute,  simple,  phlegmonous, 
toxic,  diphtheric,  and  chronic.  Einhorn  approaches  the  simple 
classification  of  Penzoldt,  and  divides  acute  gastritis  into  (i)  simple. 


NATURE    AND    CONCEPT    OF    GASTRITIS.  417 

(2)  phlegmonous,  and  (3)  toxic,  and  then  proceeds  to  the  considera- 
tion of  chronic  gastritis. 

Alois  Pick  describes  (i)  acute,  (2)  infectious,  (3)  phlegmonous, 
(4)  toxic,  (5)  parasitic,  and  (6)  chronic  gastritis  ("Vorlesungen  tiber 
Magen-  u.  Darmkrankheiten, "  S.  73);  and  Fleiner  ("Lehrbuch  d. 
Krankheiten  d.  Verdauungsorgane")  gives  an  account  of  (i)  gastritis 
catarrhalis  acuta,  for  which  he  also  uses  the  name  gastricismus ;  (2) 
gastritis  toxica;  (3)  interstitial  suppurative  gastritis,  stomach  ab- 
scess and  stomach  phlegmone,  or  gastritis  phlegmonosa  or  intersti- 
tialis,  or  submucosa  purulenta,  or  also  linitis  suppurativa ;  (4)  myco- 
tic gastric  inflammations ;  (5)  chronic  gastritis. 

Osier,  in  his  new  "Principles  and  Practice  of  Medicine,"  pages  348 
and  359,  considers  (i)  acute  simple,  (2)  phlegmonous  or  acute  sup- 
purative, (3)  toxic,  (4)  diphtheric  or  membranous,  (5)  mycotic  or 
parasitic,  and  (6)  chronic  gastritis.  Under  the  last  he  gives  a  special 
paragraph  to  the  chronic  forms  with  extreme  connective-tissue  pro- 
liferation and  increase  in  thickness  of  the  submucosa  and  muscularis, 
under  the  name  of  sclerotic  gastritis. 

These  references  are  sufficient  to  demonstrate  the  discrepancy 
existing  in  later  works  concerning  the  separate  and  distinct  recog- 
nition of  the  various  forms  of  this  disease,  and  that  a  more  uniform 
classification  would  be  desirable. 

In  accordance  with  Penzoldt,  this  treatise  will  describe  only  (i) 
simple  acute  gastritis,  (2)  simple  chronic  gastritis,  and,  separately, 
(3)  the  forms  in  which  the  element  of  pus  formation  is  a  factor — the 
suppurative  gastric  inflammations;  and  in  a  supplement  the  forms 
due  to  toxic  or  corrosive  agents,  and  the  remaining  very  rare  varie- 
ties, may  be  appropriately  described. 

Nature  and  Concept. — One  should  be  very  careful  not  to  diagnose 
every  temporary,  transient  gastric  disturbance  as  acute  gastritis,  nor 
a  prolonged  loss  of  appetite,  with  eructations,  coated  tongue,  and  no 
other  demonstrable  signs  and  symptoms,  as  chronic  gastritis — this  is, 
in  the  majority  of  such  cases,  neither  justifiable  nor  conducive  to  the 
scientific  development  of  diagnosis.  It  is  inconceivable  that  all 
the  functional  and  anatomical  changes  which  one  is  accustomed  to 
find  in  acute  inflammations  in  other  tissues  should  really  be  present  in 
every  .brief  digestive  disturbance  after  dietetic  errors,  alcoholic  abuse, 
etc. 

We  could  not  designate  a  brief  irritation  of  the  nose,  with  sneezing 
and  secretion  of  mucus,  lasting  several  hours,  as  nasal  catarrh.     By 


41 8  ACUTE    GASTRITIS. 

catarrh  of  the  air-passages  we  understand  a  more  lasting  affection, 
with  a  somewhat  typical  course,  and  more  permanent  changes,  of 
both  a  structural  and  functional  nature,  in  the  mucosa.  Indeed, 
Sydney  Martin  very  appropriately  considers  these  functional,  lighter 
forms  of  gastric  disturbance  in  separate  chapters,  and  classifies  them 
under  (i)  gastric  irritation  and  (2)  gastric  insufficiency.  Functional 
disorders,  then,  are  irregularities  of  gastric  motiHty,  absorption,  and 
secretion,  and  also  of  the  innervation  and  vascular  supply,  in  which 
organic  diseases  of  the  stomach — ulcer,  gastritis,  neoplasm,  etc. — are 
absent.  It  can  not  with  certainty  be  stated  that  all  histological 
changes  are  absent  in  functional  disorders;  at  least  not  in  functional 
disorders  of  secretion.  We  have  become  convinced  of  certain  changes 
in  the  acid  and  ferment  cells  that  are  apparently  quite  constant. 

Ever  since  Beaumont's  pioneer  observations  it  has  been  known 
that  every  severe  inflammatory  irritation  of  the  gastric  mucosa  pro- 
duces an  alteration  in  the  gastric  secretion,  the  quantity  and  effective- 
ness of  which  is  much  reduced ;  it  is  known,  furthermore,  that  the  im- 
pairment of  one  function  of  the  stomach,  as  a  rule,  rapidly  involves 
that  of  another.  The  inner  lining  of  the  stomach  can  not,  in  the  true 
anatomical  meaning  of  the  word,  be  called  a  mucous  membrane,  be- 
cause it  is  devoid  of  one  of  the  essential  attributes  of  a  mucous  mem- 
brane— the  mucous  glands.  The  mucus  of  a  normal  stomach  is  sur- 
prisingly smaU  in  amount  (see  chapter  on  Examination  of  Stomach 
Contents),  and  owes  its  origin  not  to  glands,  but  to  mucoid  degenera- 
tion of  the  superficial  columnar  epithelial  cells. 

As  this  cylindrical  epithelium  continues  down  into  the  alveoli  of 
the  peptic  tubules  without  any  distinct  border  line,  all  irritants  strik- 
ing the  former  must  of  necessity  affect  the  parietal  or  border  cells  as 
well  as  the  chief  cells  of  the  gland-duct.  It  is  characteristic  of  the 
pathology  of  gastric  digestion  that  impairment  of  one  important 
function,  or  rather  of  one  of  the  many  physiological  processes  of  which 
the  digestive  act  is  composed,  soon  creates  sympathetic  disturbance 
in  the  remaining  functions,  so  that  the  clinical  picture  of  an  acute  or 
a  chronic  gastritis  is  that  of  a  combination  of  disturbances. 

It  is  not  established,  nor  very  essential,  which  function  suffers  first, 
but  probably  in  most  cases  a  derangement  of  secretion  or  of  motility 
starts  the  morbid  series,  and  the  remaining  functions  follow  in  the 
affection.  For  example :  If  by  ingestion  of  food  which  is  already  in  a 
state  of  fermentation  an  acute  gastritis  has  been  induced,  the  reduc- 
tion in  the  amount  of  hydrochloric  acid  produces  a  hindrance,  not 


NATURE    AND    CONCEPT    OF    GASTRITIS.  419 

only  in  the  normal  chemistry  of  the  stomach,  but  resorption  and 
motility  are  also  very  soon  retarded.  This  pronounced  subacidity 
has  in  its  consequence  an  imperfect  digestion  of  the  proteids,  so  that 
very  small  amounts  of  acid  albumin  and  hemialbumose  are  detectable 
in  the  vomit,  and  peptone  is  found  in  traces  only.  A  further  step, 
then,  is  that  these  undigested  proteids  continue  to  remain  in  the 
stomach  longer  than  with  normal  proteolysis.  This  means  a  much 
more  prolonged  burdening  of  the  gastric  walls ;  the  stomach  does  not 
gain  sufficient  rest  in  which  to  prepare  itself  for  the  demands  of  the 
following  meal;  the  distention  by  the  weight  of  the  food  lasts  longer. 

On  the  other  hand,  much  more  of  the  carbohydrates  will  in  this 
subacidity  be  converted  into  soluble  starch,  maltose,  and  dextrose, 
than  with  a  normal  secretion  of  hydrochloric  acid.  With  the  pro- 
gressing stagnation  and  putrefaction  of  proteids,  these  products  of 
starch  inversion  mean  more  ready  food  for  bacteria,  which  are  con- 
stantly introduced  with  the  saliva,  and,  finding  in  the  moisture  and 
suitable  temperature  of  the  gastric  contents  congenial  conditions  for 
their  development,  the  danger  of  progressive  decomposition  is  very 
great.  The  toxic  products  of  this  carbohydrate  and  proteid  decom- 
position are  irritants  to  the  mucosa,  and  increase  the  already  existing 
inflammation. 

When  this  inflammation  has  reached  a  certain  stage,  an  inflamma- 
tory edema  of  the  muscular  layer  sets  in,  effectually  destroying  the 
motility,  and  simultaneously  (as  in  most  all  serous  and  mucous  in- 
flammations) an  alkaline  transudate  exudes  into  the  mucosa,  neu- 
tralizing the  last  vestige  of  hydrochloric  acid  that  may  yet  be  secreted. 
Lactic,  butyric,  and  acetic  acid  are  evolved  from  the  fermenting 
carbohydrates,  and,  further  on,  H2CO3  and  H. 

When  these  gases  begin  to  expand,  and  the  already  impaired  mo- 
tility can  not  expel  them  by  eructation,  the  stomach  is  still  further 
distended.  The  normal  hydrochloric  acid  not  only  acts  as  an  anti- 
septic and  antifermentative,  but,  as  we  know,  undoubtedly  brings 
about  energetic  peristalsis,  which  effects  a  thorough  mixing  of  the 
ingesta,  and,  frequently,  repeated  contact  and  friction  with  those 
portions  of  the  secretory  membrane  whose  glands  produce  the  hydro- 
chloric acid  and  ferments.  This  mixing  and  triturating  peristalsis 
is  at  the  same  time  a  most  essential  stimulus  to  absorption,  and 
eventually  effects  the  timely  expulsion  of  the  chyme  into  the  duo- 
denum. 

With  impaired  motility,  therefore,  the  food  masses  remain  too  long 


420  ACUTE    GASTRITIS. 

in  one  and  the  same  place.  An  intimate  contact  of  the  ingesta  with 
the  membrane,  as  is  produced  by  healthy  peristalsis,  is  essential  for 
normal  stimulation  to  continued  secretion;  hence,  the  secretion  of 
the  oxyntic  and  ferment  cells,  already  damaged  by  inflammatory 
infiltration,  soon  ceases  entirely.  Resorption  is  not  only  impaired 
by  absence  of  intimate  contact  with  ingesta,  but  by  the  fact  that  the 
epithelial  surface  is,  in  the  various  forms  of  gastritis,  covered  with  a 
tough,  glassy  mucus,  epithelial  detritus,  and  sometimes  pus.  In 
addition  to  this,  one  must  not  overlook  the  element  of  the  effects  of 
the  inflammatory  changes  on  the  rate,  tonicity,  quality,  and  quan- 
tity of  the  circulation  on  all  of  the  gastric  functions. 

The  damaging  effects  of  inflammation  might  be  parth"  made  up 
again  by  a  healthy  peristalsis,  but,  as  this  is  not  present,  resorption 
and  secretion  are  inhibited.  The  suspension  of  the  resorption  must 
be  looked  upon  as  an  act  of  self -protection,  as  there  are  nothing  but 
poisons  to  absorb  in  these  conditions.  There  is,  fortunately,  no 
excessive  formation  of  peptone,  as  this  is  prevented  by  the  subacid- 
ity.  We  say  "fortunately,"  because  it  would  simply  be  food  for 
bacteria.  So  it  is  evident  that,  in  an  acute  gastritis,  there  are  numer- 
ous concurrent  deleterious  elements  and  changes  which  are  essentially 
similar  to  those  of  most  light  and  severe  gastric  inflammations. 

The  clinical  picture  is  a  very  manifold  one,  as  in  the  individual 
cases  one  may  observe  first  one  and  then  another  function  that  is  most 
seriously  damaged.  It  is  natural  to  obser^*e  exceptions  from  the 
rule:  thus,  in  prolonged  anacidity  we  may  find  cases  in  which  the 
motility  is  unimpaired,  which,  of  course,  favors  intestinal  digestion 
by  timely  evacuation  of  the  chyme,  so  that  eA'en  the  symptoms  of 
dyspepsia  may  be  lacking. 

Etiology. — In  the  majority  of  cases  acute  simple  gastritis  is  caused 
by  errors  in  diet.  Irritation  may  be  caused  by  quantit}'  as  well  as  by 
quality  of  the  food.  Decomposed  articles  of  liquid  or  solid  nature 
will  set  up  inflammation  through  the  bacteria  and  toxins  they  con- 
tain. These  germs  must  not  be  thought  to  invade  the  mucosa  proper 
in  all  cases;  they  exert  effects  by  their  chemical  products.  Ewald 
(loc.  cit.)  says  he  has  never  found  bacteria  in  the  gastric  tissues  in 
these  cases.  Spoiled  or  decomposed  meat,  fish,  or  vegetables,  cheese, 
wine,  cider,  or  beer  that  has  not  completed  its  fermentation,  infected 
milk,  and  impure  pond  water  have  been  known  to  produce  severe 
acute  gastritis. 

Excessive  indulgence  in  perfectly  healthy  food  can  provoke  the 


ETIOLOGY   Q-P   GASTRITIS.  42 1 

trouble,  not  only  by  the  mechanical  distention  and  irritation  which 
are  caused  thereby,  but  by  the  inability  of  the  motive  power  to  move 
the  ingesta  about  and  to  expel  them  into  the  duodenum,  and  also  by 
the  deficiency  in  the  secretion  of  gastric  juice,  which  may  be  able  to 
digest  a  normal  but  not  an  excessive  amount  of  food.  The  amount 
that  can  be  digested  under  normal  conditions  without  causing  acute 
gastritis  will  naturally  vary  considerably  in  different  individuals. 

Chetnical  Causes. — Among  these  may  be  mentioned  quinin  salts  in 
large  doses ;  all  metallic  salts,  particularly  those  of  copper,  antimony, 
arsenic,  lead,  gold,  mercury,  and  silver;  acids  and  alkalies,  unless 
properly  diluted. 

We  have  observed  an  acute  gastritis  follow  the  use  of  two  gm.  of 
sodium  salicylate  three  times  daily,  and  feel  convinced  that  iodid  of 
potassium,  if  not  given  properly  mixed  with  food  (right  after  meals), 
may  lead  up  to  gastritis.  The  various  drugs  used  internally  for 
gonorrhea — cubebs,  copaiba,  and  the  oil  of  sandalwood — may,  in  sus- 
ceptible individuals,  bring  about,  after  long  use,  a  condition  of  the 
gastric  mucosa  in  which  acute  gastritis  is  readily  set  up. 

Psychic  Causes. — It  is  said  that  grief,  sorrow,  terror,  anger,  and 
even  excessive  joy  (?),  have  been  observed  to  produce  gastritis. 
Sexual  excesses,  particularly  in  neurasthenics,  are  on  record  as  causes. 

Thermic  Causes. — Large  quantities  of  very  cold  or  very  hot  liquids, 
particularly  the  former,  can  produce  the  disease  when  taken  in  rapidly 
when  the  body  is  in  an  overheated  state. 

Mechanical  Causes. — It  is  possible  that  pieces  of  fish-bone,  egg 
shells  or  oyster  shells,  or  fruit  seeds,  if  accidentally  ingested,  may,  by 
mechanically  scratching  or  bruising  the  mucosa,  cause  a  gastritis. 
We  had  occasion  to  observe  a  singular  case  of  this  disease  in  a  pro- 
fessional base-ball  player,  caused  by  a  blow  from  a  base-ball  pitched 
with  great  speed.  The  bruise  extended  from  the  xiphoid  cartilage  to 
the  left  hypochondriac  region.  The  player  was  knocked  senseless, 
and,  after  partial  recovery,  vomited  a  meal,  which  he  had  taken  two 
hours  before,  mixed  with  blood  and  much  mucus ;  later  on  he  vomited 
some  milk  that  was  given  him,  and  on  being  tested,  this  vomit  was 
alkaline. 

The  pain  was  so  severe  that  morphin  had  to  be  injected  hypoder- 
mically,  and  food  was  kept  out  of  his  stomach  altogether  for  three 
days,  during  which  period  he  was  fed  by  Boas'  nutrient  enema.  The 
attack  lasted  two  weeks,  and  the  patient  made  a  perfect  recovery,  free 
HCl  reappearing  at  the  end  of  the  first  week. 


422  ACUTE   GASTRITIS. 

Predisposition. — Manassein  has  shown  that  fever  produced  experi- 
mentally in  dogs  which  he  had  made  anemic  by  depriving  them  of 
much  blood,  caused  considerable  suppression  of  the  secretion  of 
hydrochloric  acid.  Kussmaul,  Uffelmann,  Leube,  and  von  den  Vel- 
den  have  confirmed  this  subacidity  in  cases  of  fever  in  the  human 
being.  It  is  not  surprising,  therefore,  if  we  find  acute  gastritis  de- 
veloping in  convalescents  from  severe  diseases ;  also  in  tuberculous, 
cancerous,  and  syphilitic  patients.  Functional  gastric  disturbances 
predispose  to  acute  gastritis  as  well  as  preexisting  or  concomitant 
diseases  of  the  heart,  lungs,  liver,  and  kidneys.  Ewald  believes  in 
hereditary  predisposition  to  gastritis,  as  some  families  show  numer- 
ous cases  of  the  trouble  in  spite  of  the  best  care  they  take  of  their 
stomachs. 

Idiosyncrasy. — It  is  a  very  perplexing  fact  that  some  persons  in 
good  health  acquire  acute  gastritis  after  eating  certain  articles  of 
food.  While  the  author  was  physician  in  charge  of  Bay  View  Hospi- 
tal, Baltimore,  he  had  a  colleague,  a  perfectly  robust,  vigorous  man, 
not  at  all  neurasthenic,  who  developed  the  disease  every  time  he  ate 
oysters.  He  could  not  be  induced  to  eat  them  after  he  had  estab- 
lished the  causal  relation,  but  convinced  us  by  consenting  to  an  ex- 
periment. 

Influence  of  Sex  and  Age. — Acute  gastritis  occurs  more  frequently 
in  men  than  in  women ;  of  60  cases  observed  by  the  author,  of  which 
records  were  taken,  1 6  occurred  in  females  and  44  in  males.  Females 
are  more  frequently  attacked  during  menstruation  and  puerperium. 
Old  persons  and  very  young,  feeble  children  are  more  likely  to  be 
attacked  than  those  in  middle  age.  In  nursing  infants  a  very  slight 
change  in  the  milk  may  be  enough  to  cause  it.  According  to  Booker, 
of  Baltimore,  acute  gastritis  in  infants  is  accompanied  by  prolonga- 
tion of  the  time  that  the  milk  is  retained  in  the  stomach,  at  times 
over  five  hours.  The  gastric  contents  occasionally  show  epithelial 
and  pus  cells. 

Rotch  ("Pediatrics,"  p.  854)  holds  that  the  acute  form  is  more 
common  in  infants,  and  that  the  chronic  form,  while  it  does  occur  in 
them,  is  more  frequent  in  children  toward  puberty.  The  frequent 
attacks  of  gastritis  occurring  during  the  hot  summer  months  are  un- 
doubtedly largely  due  to  the  consumption  of  unripe  fruit.  Bouveret, 
however  ("Traite  des  Maladies  de  rEstomac,"  p.  384,  Paris,  1893), 
attributes  them  to  the  abusive  consumption  of  water.  According  to 
Pick,  the  disease  has  been  observed  to  develop  after  taking  cold. 


PATHOLOGICAL   HISTOLOGY.  423 

The  effect  of  fever  on  the  secretions  of  the  stomach  is  not  always 
evident.  Edinger  found  the  secretion  of  hydrochloric  acid  normal 
in  five  cases  of  fever ;  having  examined  hectic,  recurrent,  intermittent 
and  typhoid  fever  patients  (L-  Edinger,  "Zur  Physiol,  u.  Path.  d. 
Magens,"  "Deutsch.  Archiv  f .  klin.  Medizin,"  Bd.  xxix,  S.  555).  G. 
Klemperer  ("Dyspepsie  d.  Phthisiker,"  "Berlin,  klin.  Wochenschr.," 
1889)  and  Schetty  ("Untersuch.  ii.  Magenfunction.  bei  Phthisis," 
"Deutsch.  Archivf.  klin.  Med.,"  Bd.  xliv,  S.  516)  confirm  the  finding 
of  Edinger.  Ewald  (loc.  cit.,  p.  301)  found  almost  normal  digestive 
power  in  a  case  of  facial  erysipelas.  From  these  studies  it  is  plain 
that  not  in  all  cases  of  secondary  acute  gastritis  can  we  attribute  the 
stomach  affection  to  the  functional  disturbances  which  the  primary 
disease  produces ;  for,  in  the  first  place,  these  may  be  entirely  absent : 
secondly,  the  frequency  of  the  gastritis  is  not  at  all  dependent  upon 
the  height  or  intensity  of  the  fever ;  thirdly,  the  secondary  sympathe- 
tic gastritis  may  set  in  concomitant  with  the  fever  or  even  before  it, 
ushering  in  the  main  infectious  symptoms  as  a  prodromal  affection. 

The  secondary  sympathetic  gastritis  is  therefore  more  likely  to  be 
originated  by  localization  of  the  specific,  organized  disease-producers 
of  the  fundamental  disturbance — in  the  mucosa  of  the  stomach,  or 
even  by  the  toxic  metabolic  products  of  these  microbes.  In  addition 
to  the  infectious  diseases  already  mentioned,  this  sympathetic  form 
may  be  a  consequence  of  diseases  of  the  heart,  lungs,  kidneys,  and 
liver,  causing  venous,  passive  congestion  of  the  gastric  mucosa 
(Stauungskatarrh) .  In  cardiac  and  nephritic  diseases  the  passive 
gastric  congestion  may  be  relieved  by  appropriate  medication  di- 
rected to  the  fundamental  disorder — i.  e.,  the  use  of  digitalis,  strych- 
nin, and  diuretics. 

Pathological  Histology. — According  to  Orth  ("Specielle  patho- 
log.  Anatomic,"  Bd.  i,  S.  702),  our  knowledge  concerning  the  patho- 
logical histology  of  the  exudative  inflammation  of  the  stomach  is 
very  limited ;  in  the  first  place,  because  uncomplicated  simple  acute 
gastritis  rarely  ends  in  death,  and,  secondly,  because  postmortem 
changes  and  autodigestion  exert  a  most  disturbing  and  disfiguring 
effect,  particularly  in  these  superficial  diseases.  In  a  case  which  M. 
Laboulbene  observed, — twenty-four  hours  after  death  by  rupture  of 
an  aneurysm, — there  existed  hyperemia  of  the  nmcosa,  localized  ec- 
chymoses,  swelling  of  the  mucous  alveoli,  and  augmentation  of  the 
mucus. 

Delafield  and  Prudden  give  essentially  these  same  changes  ("Text- 
28 


424 


ACUTE   GASTRITIS. 


book  on  Pathology"),  also  Ziegler  ('%elirbucli  d.  allg.  und  spec, 
pathol.  Anat.,"  Jena,  1890),  which  may  be  summarized  as  follows: 
The  surface  of  the  mucosa  is  covered  by  a  tough,  glassy,  cloudy,  or 
reddish  mucus.  The  mucosa  itself  is  injected,  swollen,  and  character- 
ized by  a  hyperemia,  which  is  limited  generally  to  the  pyloric  re- 
gion, and  rarely  extends  to  the  entire  mucosa.  Red  spots,  either 
well  circumscribed  or  diffuse,  are  very  evident,  and  ecchymoses  are 
scattered  throughout  the  mucous  membrane.  Large  suggillations 
occur  also,  but  are  rare. 

The  histological  changes  are,  by  most  German  authors,  said  to  be 
out  of  proportion  to  the  degree  and  intensity  of  the  symptoms 
(Fleiner,  loc.  cit.,  p.  233) :  that  is  to  say,  they  expect  a  greater  exten- 
sion and  degree  of  inflammation  to  correspond  to  the  severity  of  the 
symptoms,  and  are  surprised  not  to  find  it.  Fischl  asserts  this  par- 
ticularly of  the  gastroenteritis  of  children  (Fleiner,  loc.  cit.,  p.  233). 
However,  the  exact  and  very  instructive  investigations  of  William 
D.  Booker  ("Johns  Hopkins  Hospital  Reports,"  vol.  vi,  pp.  159-258, 
plates  XVI  to  xxi)  show  quite  the  contrary.  Booker's  researches  de- 
monstrate destruction  of  the  superficial  epithelium  in  parts  and  infil- 
tration of  the  mucosa  with  polynuclear  leukocytes.  Many  oxyntic 
■cells  are  without  nuclei,  and  show  only  loose,  granular  protoplasm 
remaining.  Epithelial  cells  and  fragments  of  glands  are  collected  in 
heaps  on  the  surface,  but  not  to  so  marked  an  extent  as  in  the  intes- 
tine (Booker,  loc.  cit.,  p.  251).  In  a  few  cases  of  acute  gastritis  asso- 
ciated with  enteritis  he  found  the  entire  gastric  mucosa  destroyed. 
Bacteriological  cultures  were  made  in  23  cases;  in  19  the  colonies 
nvere  very  numerous,  in  two  moderately  numerous,  and  in  two  there 
"were  no  colonies  of  bacteria,  but  many  of  oidium  albicans.  Tabu- 
lated, his  results  appear  as  follows : 


Predom- 
inant. 

Numer- 
ous. 

Few. 

,  Absent. 

Pure 
Culture. 

Oidium  albicans, 

Bacillus  coli  communis,      .    .    . 
Bacillus  lactis  aerogenes,  .    .    . 

Proteus  vulgaris, 

Streptococci,    .  , 

Cases. 
3 

7 
3 
0 

Cases. 
3 
8 
2 
0 
4 

Cases. 

I 
4 
5 
2 

3 

Cases. 

14 

6 

7 
18 
16 

Cases. 
0 
0 
2 
0 
0 

Booker,  like  A.  Czerny  and  P.  Moser,  concludes  that  the  gastro- 
enteritis of  children  is  a  general  infectious  disease,  with  autointoxica- 
tion, in  which  other  organs  of  the  body  participate,  either  as  a  result 


PATHOLOGICAL    HISTOLOGY.  425 

of  an  invasion  of  the  body  by  bacteria,  as  is  often  the  case  with  the 
lungs,  or  from  the  effects  of  poisons  absorbed  from  the  gastrointesti- 
nal canal.  This  infantile  digestive  affection  is  undoubtedly  a  more 
severe  and  acute  disease  than  any  gastritis  that  occurs  in  adults,  but 
its  study  certainly  aids  our  knowledge  of  the  allied  pathological  states 
of  adults.  There  are  a  number  of  inflammations,  occurring  in  adults 
as  well  as  children,  that  are  followed  or  preceded  by  digestive  disor- 
ders, the  etiology  of  which  is  much  cleared  up  by  the  work  of  the 
authors  above  mentioned.  We  refer  to  the  obscure  attacks  of  paroti- 
tis, tonsilhtis,  and  pharyngeal  abscess  sometimes  following  well- 
defined  gastric  ulcer,  and  to  the  disorders  of  the  heart  and  nervous 
system  concomitant  or  succeeding  gastrointestinal  lesions. 

These  secondary  attacks  at  times  may  be  autointoxications ;  then, 
again,  they  show  the  unmistakable  signs  of  direct  infection  secondary 
to  digestive  trouble,  for  in  the  superficial  epithelium  is  to  be  found 
the  chief  protection  of  the  mucosa  against  the  invasion  of  bacteria. 
When  the  epithehum  is  well  preserved,  bacteria  are  not  found  in  the 
mucosa  beneath,  whereas  they  may  be  seen  entering  it  where  the  epi- 
thehum has  been  lost  or  injured  (Booker,  loc.  cit).  The  first  step  in 
the  pathological  process  is  probably  an  injury  to  the  epithelium  from 
abnormal  or  excessive  fermentation  in  the  stomach,  or  from  toxic 
products  of  bacteria  and  the  many  other  conditions  that  have  already 
been  described.  (See  Plate  VII.)  To  prevent  the  effects  of  auto- 
digestion  and  postmortem  digestion  on  the  gastric  mucosa,  Ewald 
suggested  washing  out  the  stomach  immediately  after  death  and 
filling  it  with  alcohol.  This  may  in  future  save  a  large  number  of 
futile  investigations.  Formerly  one  depended  largely  on  the  studies 
of  gastritis  experimentally  produced  in  animals  for  recognition  of  the 
pathological  changes.  Thus,  Ebstein  produced  gastritis  by  injecting 
absolute  alcohol  into  the  stomachs  of  dogs. 

Ewald  and  Ebstein  describe  a  granular,  cloudy  swelling  in  the 
superficial  epithelium.  While  there  is  no  differentiation  possible 
between  the  parietal  or  oxyntic  and  the  central,  chief,  or  ferment  cells, 
both  varieties  are  either  swollen  or  contracted,  granular,  cloudy,  and 
with  very  indistinct  nuclei.  Between  the  different  epitheha  and  in 
the  interglandular  connective  tissue  there  are  considerable  masses  of 
round  cells.  In  these,  as  well  as  in  the  emigrated  leukocytes  and  the 
cyhndrical,  superficial  cells,  numerous  karyokinetic  figures  are  very 
evident,  and  were  claimed  by  Sachs  {loc.  cit.)  to  be  characteristic  of 
acute  gastritis,  but  this  is  denied  by  Ewald. 


426  ACUTE    GASTRITIS. 

Beaumont  (Joe.  cit.)  gives  some  strikingly  correct  descriptions  of 
the  conditions  observed  in  the  stomach  of  his  patient,  Alexis  St. 
Martin,  when  it  was  acutely  inflamed  in  consequence  of  overfeeding 
or  of  abuse  of  alcoholic  beverages.  He  states  that  the  mucosa,  even 
when  no  digestion  was  going  on,  was  mostly  very  hyperemic,  swollen, 
and  covered  with  a  thick  layer  of  tough  mucus.  After  ingestion  the 
food  was  not  digested,  but  remained  undigested  in  the  stomach  from 
four  to  six  hours.  The  secretion,  which  was  much  diminished,  was 
only  rarely  faintly  acid;  mostly  it  was  found  alkaline  or  neutral. 
After  a  few  days  the  mucus  became  still  thicker,  but  the  hyperemia 
grew  less.  This  and  the  following  account  of  Beaumont  on  the  state 
of  the  mucosa  in  gastritis — ' '  its  surface  was  marked  with  numerous 
white  spots  and  vesicles  like  coagulated  lymph,  between  which  were 
ver}^  dark  red  spots" — are  considered  by  Kleiner  (p.  232,  loc.  cit.)  and 
Fleischer  (p.  802,  loc.  cit.)  as  unintelligible  in  the  light  of  our  present 
knowledge.  These  remarks  of  the  American  pioneer  of  gastric  pathol- 
ogy, considered  in  that  very  light,  impress  us  as  a  siu-prisingly  acute 
and  exact  description  of  the  mucosa  in  certain  types  of  gastritis,  and 
inspire  the  latter-day  student  with  respect  for  the  powers  of  observa- 
tion in  the  man.  Fisch  ("Fleiner's  lyehrbuch,"  p.  233),  after  what  he 
considers  very  detailed  and  careful  investigations,  differentiates  three 
forms  of  gastritis  in  children:  (i)  An  interstitial  gastritis,  which  he 
supposes  to  start  from  the  connective  tissue;  (2)  a  parenchymatous 
inflammation  having  its  seat  in  the  glandular  tubes ;  and  (3)  a  com- 
bined parenchymatous  interstitial  inflammation.  The  interstitial 
affection  may  be  interglandular  or  submucous. 

Symptomatology  and  Course. — Immediately  after  gross  insults 
to  the  gastric  physiology,  characteristic  signs  and  symptoms  appear. 
These  are  fullness  in  the  epigastrium,  which  is  distended  and  painful 
on  pressure;  eructation,  which  at  first  may  bring  relief,  later  on  in- 
creases so  as  to  be  a  great  annoyance ;  thirst,  anorexia,  and  even  dis- 
gust for  food,  may  accompany  this.  The  tongue  is  often  thickly 
covered  with  a  tenacious  white  fur,  retaining  the  impressions  of  the 
teeth,  and  colored  by  food  or  drugs;  the  breath  is  offensive.  The 
secretion  of  saliva  is  augmented,  the  pulse  small  and  rapid.  There 
may  be  painful  contractions  of  the  esophageal  musculature,  spas- 
modic yawning,  and  herpes  labialis.  A  burning  pain  in  the  epigas- 
trium, which  ma}^  radiate  to  the  hypochondriac  region,  arises  under 
the  sternum  (pyrosis)  toward  the  throat,  causing  burning  all  the  way, 
*  and  sometimes  raising  sour  or  bitter  stomach  contents.     As  water 


SYMPTOMS   AND    COURSE.  42? 

and  other  liquids  diminish  the  gastric  burning,  the  patients  usually 
show  great  thirst.  The  appetite,  however,  is  absent,  or  there  is  a 
perverse  craving  for  piquant,  acid,  or  salty  foods,  while  the  habitual 
diet  is  detested.  Taste  is  much  disturbed.  The  nervous  symptoms 
are  general  malaise,  indisposition  to  mental  or  bodily  work,  prostra- 
tion, and  frontal  and  occipital  headache.  Palpitation  of  the  heart, 
giddiness,  and  a  feeHng  of  fear,  with  profuse  sweating,  are  sometimes 
present.  Nervous  and  less  resistant  patients  (children)  may  have 
delirium.  Fleiner  declares  that  general  convulsions  or  loss  of  con- 
sciousness are  not  rare  in  his  experience. 

All  these  symptoms  may  arise  directly  from  the  stomach  or  reflexly 
from  the  central  nervous  system,  which  in  these  cases  suffers  intensely 
at  times  through  the  absorption  of  toxins  from  the  stomach.  If  the 
nausea  increases  to  emesis,  there  will  be  at  first  vomiting  of  food  that 
has  been  eaten  many  hours  before.  This  vomited  material  is  mostly 
badly  digested,  and  imbedded  in  mucus.  After  emesis  the  symp- 
toms may  amehorate  and  the  nausea  cease;  very  frequently,  how- 
ever, the  vomiting  continues  when  no  more  food  is  in  the  stomach. 
Then  saliva,  mucus,  bile,  and  even  blood,  may  be  forced  up  under  great 
retching  and  suffering.  Intestinal  parasites  have  in  this  way  been 
forced  into  the  stomach  and  vomited.  Skoda  first  directed  attention 
to  cases  in  which  vomiting  was  much  impeded  (at  times  prevented) 
by  spasm  of  the  sphincters,  particularly  at  the  cardia. 

If  the  last  meals  contained  an  abundance  of  carbohydrates  or  fats, 
the  vomited  material  will,  on  testing,  show  an  abundance  of  lactic, 
butyric,  and  fatty  acids ;  it  will  also  contain  acetic  acid  from  the  alco- 
hol which  was  either  the  cause  of  all  the  difficulty  or  which  has  been 
administered  by  sympathizing  laymen.  But  the  most  characteristic 
chemical  condition  is  the  entire  absence  of  free  hydrochloric  acid  in 
the  vomilied  matter,  which  is  the  cause  of  the  perverse  fermentations 
and  decomposition  in  the  gastric  contents. 

The  occurrence  of  hydrogen  sulphid  in  the  contents  of  the  stomach 
and  in  the  urine,  which  has  been  reported  by  Senator,  indicates  a 
degree  of  albuminoid  decomposition  which  is  extremely  rare. 

State  of  the  Urine.— The  quantity  is,  as  a  rule,  diminished ;  in  febrile 
cases  the  specific  gravity  is  high,  and  when  constipation  is  present,  it 
contains  an  excess  of  indican. 

Fever.— While  about  one-half  of  the  cases  transpire  without  rise 
of  temperature,  in  the  other  half  fever  is  present,  appearing  sud- 
denly, and  reaching  at  times  105°  F.  (40°  C).     This  form  may,  in 


428  ACUTE    GASTRITIS. 

the  beginning,  occasion  some  difficulty  in  the  diagnosis,  because  of  its 
strong  resemblance  to  typhoid  fever.  Under  these  circumstances 
Widal's  reaction  for  typhoid  fever,  by  the  effect  of  the  serum  of  such 
patients  on  the  clumping  of  the  typhoid  bacillus,  should  be  carried 
out  for  diagnostic  differentiation  ("Le  Bulletin  Medical,"  1896,  Nos. 
59,  61,  64,  78,  83;  1897,  No.  4).  Also  C.  Frankel  ("Deutsch.  med. 
Wochenschr.,"  1897,  No.  3)  and  Wyatt  Johnson  ("N.  Y.  Med.  Jour.," 
Oct.,  1896,  and  "Med.  News,"  Jan.,  1897).  Some  German  writers 
still  speak  of  gastric  fever  as  an  infectious  disease  peculiar  to  itself. 
(See  F.  Schmidt,  "Dissertation,"  Berlin,  1885;  "Z.  Frage  d.  Existenz 
d.  gastrisch.  Fiebers,  als  einer  eigenartigen  Krankheit  ";  Hans  Herz, 
loc.  cit.,  p.  95.)  The  cases  described  as  such  are  no  doubt  mild  cases 
of  enteric  fever. 

Though  it  is  difficult  to  furnish  proof  of  a  direct  infection  in  these 
febrile  forms  at  present,  it  is  not  at  all  impossible  that  such  a  gastritis 
may  exist.  Future  bacteriological  studies  in  this  disease  may  throw 
much  light  on  this  point.  The  fever  of  acute  gastritis  is  usually  pre- 
ceded by  repeated  chilly  sensations  or  by  a  typical  shaking  chill. 

Duration. — If  the  rules  of  hygiene  are  regarded  and  the  patient  ob- 
serves a  careful  diet,  the  disturbances  will  disappear  entirely  in  from 
three  to  four  days.  There  are,  of  course,  much  shorter  attacks.  The 
stomach  remains  very  sensitive  to  errors  of  diet,  etc.,  for  a  varying 
time.  A  number  of  neglected  cases,  or  those  occurring  in  very  weak- 
ened individuals,  may,  by  a  gradual  transition,  turn  to  the  subacute 
or  chronic  form. 

Diagnosis. — In  cases  that  are  not  accompanied  by  any  fever  there 
should  be  no  difficulty  in  determining  the  nature  of  the  disease,  espe- 
cially as  the  direct  cause  is,  in  most  instances,  apparent.  The  febrile 
form  may  be  confounded  with  beginning  enteric  fever;  during  the 
first  three  days  of  the  attack  it  may  be  impossible  to  differentiate  the 
two,  Widal's  method  giving  a  negative  result  if  instituted  before  the 
second  week  of  typhoid  fever.  The  existence  of  fever  blisters  (herpes 
labialis),  which,  according  to  Leo  (Joe.  cit.,  p.  66),  speaks  against  ty- 
phoid, is,  in  our  experience,  an  unreliable  sign;  the  results  of  the 
blood  examinations  are  contradictory,  and  in  the  urine  no  diagnostic 
feature  is  known.  The  diazo  reaction  of  Ehrlich,  even  when  per- 
formed in  the  originator's  latest  method  ("Charite  Annalen,"  1886, 
Bd.  11),  has,  in  our  experience,  been  of  no  diagnostic  value.  In  this 
respect  we  can  confirm  the  opinions  of  von  Jaksch  and  Eichhorst 
("Klinische    Untersuchungsmethoden, "    p.    177).     Most    infectious 


PROGNOSIS    AND   TREATMENT.  429 

diseases  (see  above)  are  in  the  beginning  accompanied  by  an  acute 
gastritis ;  in  most  of  them,  particular!}^  the  exanthemata,  a  differen- 
tiation is  not  difficult.  It  is  good  advice  that  von  Leube  ("Specielle 
Diagnose,"  i.  Theil,  Leipzig)  gives  when  he  says:  "In  all  cases  with 
high  fever  think  of  other  sources  and  causes  before  settling  upon  gas- 
tritis." There  are  two  conditions  which,  so  far  as  can  be  judged  at 
present,  are  reliable  factors  in  the  earty  diagnosis  between  acute  gas- 
tritis and  enteric  fever.  (The  early  diagnosis  is  the  only  one  we  are 
discussing;  the  element  of  time  is  very  important  here,  as  simple 
gastritis  is  only  of  three  days'  duration.)  The  differentiating  factors 
are  the  manner  and  rise  of  the  fever  and  the  state  of  the  spleen. 

In  enteric  fever  we  mostly  meet  with  a  gradual  rise  of  temperature 
and  a  gradual  fall  when  the  fever  subsides.  In  gastritis  the  tempera- 
ture rises  abruptly,  the  remissions  are  slighter,  and  the  fall  is  more 
sudden.      (See  Osier,  "Prin.  and  Prac.  of  Med.,"  p.  349.) 

Therefore  frequent,  regular,  thermometrical  studies  are  not  to  be 
omitted.  The  second  diagnostic  sign  of  value  is  the  presence  or  ab- 
sence of  splenic  tumor;  its  presence  points  to  enteric  fever.  Un- 
fortunately, the  splenic  enlargement  is  not  invariably  present  in 
enteric  fever  at  the  outset.* 

Prognosis. — Speaking  generally,  the  prognosis  of  simple  acute' 
gastritis,  except  in  very  old  patients  and  in  young  children,  is 
favorable. 

Treatment. — i.  Prophylactic.     2.  Dietetic.     3.  Medicinal. 

Prophylactic  treatment  will  especially  be  applicable  to  cases  that 
are  known  to  have  enfeebled  digestive  organs  or  in  which  attacks  of 
digestive  disease  have  repeatedly  occurred.  Attention  must  be 
directed  to  avoidance  of  injurious  influences  that  may  affect  the 
stomach  direct  from  external  causes  and  those  that  affect  it  from 
internal  causes. 

(a)  The  external  causes  are,  of  course,  the  manifold  varieties  of 
trauma  that  are  possible  in  modern  life;  not  only  those  that  can 
occur  accidentally,  but  those  that  occur  gradually  by  pressure  upon 
the  abdomen  from  without,  such  as  are  requisite  in  the  execution  of 


*  Dr.  Edward  I,.  Whitney  and  myself  observed  in  1897  tliat  the  VVidal  test  for  typhoid 
fever  failed  when  instituted  during  the  first  week.  Apparently,  a  certain  time  is  required 
before  the  serum  acquires  the  characteristic  effect  on  the  typhoid  bacilli.  This,  of  course, 
— if  confirmed  by  further  observations, — would  render  it  useless  in  the  early  differential 
diagnosis  between  typhoid  fever  and  acute  gastritis,  because  the  duration  of  the  latter  is 
only  a  few  days. 


430  ACUTE   GASTRITIS. 

certain  trades,  the  manipulation  and  handling  of  machines,  and  even 
the  continuous  pressure  of  tables. 

A  very  important  matter  in  this  respect  is  clothing,  particularly 
that  of  the  female  sex.  Their  clothing  of  to-day,  as  far  as  the  main- 
tenance of  healthy  digestive  organs  is  concerned,  is  not  at  all  con- 
formable to  this  object.  The  nmch-condemned  corset  is  not  even 
the  worst  part  of  the  female  outfit,  for  a  properly  constructed  and 
correctly  applied  corset  does  not  necessarily  effect  damage;  but  it 
would  be  more  hygienic  to  discard  it  altogether,  and  preserve  form 
and  insure  support  to  the  breast  and  graceful  carriage  in  the  style  of 
the  ancient  Greeks  (Grecian  corset),  or  by  broad,  soft  bandages  ap- 
plied immediately  to  the  skin,  over  the  underwear,  or  even  externally 
(Julia  Marlowe  style) .  More  harmful  than  the  corset  is  the  tying  of 
the  skirts  and  dresses  around  the  waist. 

The  most  judicious  clothing  conformable  to  the  object  of  relieving 
the  abdominal  organs  of  pressure  is  represented  by  garments  made  in 
one  piece,  of  which  the  upper  part  supports  the  lower  from  the  shoul- 
ders (Kleinwachter,  "Deut.  Med.  Zeitschr.,"  1894,  S.  82;  also  Mei- 
nert,  "Volkmann's  klin.  Vortrage,"  115,  116). 

The  abdomen  should  always  be  kept  warm,  not  by  special  ban- 
dages, but  by  garments  that  are  made  of  wool,  fitting  quite  comforta- 
bly to  the  skin,  and  closed  below — i.  e.,  over  the  genito-urinary  organs 
and  rectum.  All  digestive  sufferers  should  take  special  care  against 
cooling  or  sudden  chilling  of  the  surface. 

(b)  The  internal  causes  or  injurious  influence  must  chiefly  be 
avoided  in  the  food.  Exclusive  of  corrosive  and  irritant  poisons  that 
may  be  swallowed  accidentally,  the  food  articles  may  contain  adul- 
terations in  the  form  of  organic  or  inorganic  additions  that  are  in- 
compatible with  sound  digestion,  or  the  food  may  be  decayed,  fer- 
menting, or  decomposed.  Among  the  adulterations  might  be  men- 
tioned that  of — 

Milk,  with  water,  sodium  carbonate  and  bicarbonate,  borax,  and 
salicylic  acid ;  or  it  may  contain  bacteria  (tubercle  and  typhoid  bacilli). 

Cheese,  adulterated  with  decomposable  gelatins,  and  may  contain 
lead  and  tin  from  the  packing,  and  also  mineral  impurities. 

Sausages  may  contain  flour,  fuchsin  (for  coloring),  organic  poisons, 
bacteria,  ptomains.     (Botuhsmus:  poisoning  by  sausage.) 

Butter  may  be  adulterated  by  mineral  substances,  gypsum,  lime, 
coloring  matters,  lead  chromate,  cresol,  dinitronaphthol,  and  the 
caustic   alkalies. 


DIETETIC   TREATMENT.  43 1 

Vegetable  Food. — Flour  has  been  found  adulterated  by  sand,  gyp- 
sum, and  alum,  and  also  mixed  with  the  fungi  of  rye  or  wheat; 
ergot  poisoning  by  rye  flour  has  been  observed  in  Russia.  Some 
confectioners  use  dye-stuffs  of  various  kinds,  all  of  which  are  dan- 
gerous. Coffee  is  sometimes  adulterated  with  copper  or  lead  salts 
to  give  it  the  desired  color.  Wine,  beer,  and  whisky  are  subject  to 
numerous  adulterations  to  effect  cheaper  manufacture,  to  preserve 
or  color,  or  to  give  any  desired  taste.  In  beer,  picric  acid,  colchicum, 
and  strychnin  have  been  found  as  substitutes  for  hops;  impure 
grape-sugar  for  malt;  alkalies  to  prevent  souring,  and  salicylic. acid, 
to  preserve  it  or  check  fermentation. 

Furthermore,  the  prophylaxis  must  be  directed  to  the  (i)  quality, 
(2)  quantity  of  the  food,  (3)  the  proper  preparation  of  the  food  by 
chewing  and  insalivation,  and  proper  conduct  after  eating. 

These  subjects  are  best  studied  in  the  section  on  Dietetics. 

Dietetic  Treatment. — Acute  inflammation  of  any  structure  is  best 
treated  by  rest,  and  the  stomach  forms  no  exception.  Hence,  total 
abstinence  from  food  and  great  reduction  of  the  quantity  of  fluid 
imbibed  is  often  curative  after  an  interval  of  thirty-six  hours.  So, 
for  the  first  two  days  as  little  food  as  possible  should  be  allowed.  To 
accomplish  this  very  simple  and  logical  object  is,  in  private  practice, 
a  most  difficult  thing.  There  is  an  incorrigible  custom  among  rela- 
tives, which  it  is  hard  to  combat,  of  stuffing  the  patient  with  all  man- 
ner of  articles.  At  the  bottom  of  all  this  probably  lies  the  popular 
superstition  that  a  human  being  can  not  exist  twenty-four  hours 
without  food.  A  total  abstinence  from  food  is  borne  very  well,  and 
leads  most  rapidly  to  recovery.  For  the  intolerable  thirst,  cracked 
ice  should  be  given,  a  wineglassful  in  two  hours.  If  there  are  signs  of 
collapse,  champagne  or  brandy  may  be  added  with  safety,  even  if 
alcohol  was  the  cause  of  the  trouble. 

After  the  twenty -four  hours  of  total  abstinence,  the  first  food  to  be 
given  is  milk  or  beef  bouillon,  with  soft  rice  or  an  egg  beaten  up  in  it. 
A  good  stimulating  food,  when  there  are  signs  of  prostration,  consists 
of  one  raw  egg  beaten  up  with  ^  of  a  pint  of  Hochheimer,  or  a  full  pint 
if  desired,  and  sweetened  to  taste,  with  a  slight  flavor  of  lemon  added. 
The  wine  may  have  to  be  diluted  if  the  gastric  mucosa  is  very  sensi- 
tive. ,  Of  the  above,  a  small  wineglassful  (two  ounces)  may  be  given 
every  two  hours  or  it  may  safest  be  given  by  enema  (quite  warm,  if 
preferred).  On  the  third  day  a  few  soda  crackers  or  cakes  may  be 
allowed.     On  the  fourth  day  a  gradual  return  to  more  reconstructive 


432  ACUTE    GASTRITIS. 

food  is  advisable,  such  as  calf's  brain,  free  from  all  stringy  and  mem- 
branous parts,  boiled  first  in  bouillon,  then  rapidly  broiled;  sweet- 
bread or  thymus  gland  broiled ;  breast  meat  of  broiled  squab,  pigeon, 
or  chicken.  Finally,  on  the  sixth  day  after  the  attack,  finely  scraped 
broiled  beef,  potato  puree,  stewed  apples,  rice,  tapioca,  very  soft  ome- 
let. A  plan  that  is  generally  successful  is  to  follow  out  the  Penzoldt 
diet  order  given  on  p.  230. 

Medicinal  Treatment. — Acute  gastritis  should  be  treated  without 
drugs  whenever  it  is  possible.  If  the  dietetic  rules  of  total  abstinence 
from  all  food  for  twenty-four  hours  and  cautious  return  to  light  diet 
are  carried  out,  three-fourths  of  the  cases  will  recover  without  medi- 
cines. Not  a  few  patients,  even  children,  will  do  this  instinctively, 
and  not  permit  any  cramming  with  food  until  the  stomach  has  be- 
come rested  and  a  natural  desire  therefor  returns.  We  have  consist- 
ently carried  out  the  starvation  treatment  in  twenty  cases  of  acute 
simple  gastritis,  allowing  nothing  but  water  or  cracked  ice  for  forty- 
eight  hours ;  they  all  recovered  without  the  use  of  drugs.  The  most 
important  indication  of  treatment  is  usually  done  by  the  organ  itself 
— i.  €.,  evacuation. 

If  emesis  does  not  occur  easily  at  the  outset,  both  Ewald  and  Boas 
recommend  the  following  emetic : 

R.     Pulvis  ipecacuanhce, 1. 5       gr.  xxiij 

Antimonii  et  potassii  tartras, 0.05     gr.  ^.  M. 

SiG. — Fiat  chart.  No.  I.      To  be  taken  at  once  or  in  divided  doses. 

In  children,  Ewald  favors  a  teaspoonful  of  the  syrup  of  ipecac.  I 
have  so  far  been  able  to  accomplish  all  that  was  necessary  without 
emetics,  and  am  loath  to  advise  their  use.  Apomorphin  hydrochlo- 
rate  may  be  used  hypodermically  in  doses  of  y^  of  a  gr.,  but  in  some 
cases  it  has  been  known  to  cause  syncope  and  collapse.  A  drug  which 
gives  satisfaction  to  both  patient  and  physician  in  these  attacks,  par- 
ticularly when  there  is  constipation,  is  calomel.  Sometimes,  when 
persistent  nausea  follows  through  emesis,  it  may  even  act  as  a  gastric 
sedative.  Ewald  advises  six  grs.,  repeated  in  an  hour.  While  this 
dose  seems  large,  it  is  by  no  means  too  large,  and  will  produce  a  chola- 
gog  and  sterilizing  effect  that  sometimes  terminates  the  gastritis  then 
and  there.  Formerly  we  used  tablet  triturates  of  ^  of  a  gr.  of  calomel 
every  hour  until  purgation;  they  are  more  pleasant  to  administer. 
The  larger  dose  recommended  by  Ewald  produces  more  of  an  antisep- 
tic action,  since  a  portion  of  it  is  converted  into  mercuric  chlorid. 

Calomel  can  not  be  given  at  the  beginning  of  the  gastritis  very  well ; 


MEDICINAL   TREATMENT.  433 

the  second  day  is  best  suited  for  its  administration.  Although  I  men- 
tion these  drugs,  it  is  not  with  a  view  to  routine  treatment,  but  to  aid 
in  meeting  special  indications.  When  pain  in  the  stomach  is  attended 
by  chilliness,  we  advise  hot  poultices  over  the  entire  abdomen,  turpen- 
tine stupes,  or  spongiopilin  dipped  in  hot  water,  and  ten  to  twenty 
drops  of  tincture  of  opium  sprinkled  over  before  it  is  applied  to  the 
epigastrium.  But  when  there  is  gastric  pressure  that  seems  to  em- 
barrass respiration,  associated  with  explosive  eructation,  cold  hydro- 
pathic applications  are  more  effective  than  hot  ones.  (For  the  tech- 
nic  of  these  applications  see  Baruch,  "Hydrotherapy.")  When 
there  is  fever,  these  applications  should  be  made  with  ice- water  or  the 
ice-bag.  Intense  pain  is  met  with  hypodermic  injections  of  morphin, 
■J  of  a  gr.,  and  atropin  sulphate,  y^-g-  of  a  gr.  The  following  supposi- 
tories of  Boas  may  be  applied : 

R .      Codein  phosphoric, 0.05  gr.  ^ 

Ext.  belladonnse, 0.03  gr.  |. 

Enough  cacao  butter  to  make  ten  suppositories. 

SiG. — One  every  hour  until  relieved.      When  the  pain  must  be  relieved,  and  the 

hypoflermic  injection  is  not  permitted  and  medication  peros  not  retained,  they 

are  very  useful. 

By  the  mouth,  codein  is  best  given  in  the  following  manner : 

R.     Codein  phosph., 0.4  gr.  vj 

Aqua  menth.  pip., 40.0         f  ^  iss.  M. 

SiG. — One  teaspoonful  every  three  hours. 

If  symptoms  of  hyperacidity,  keeping  up  the  annoying  pyrosis  and 
thirst,  are  predominant,  it  may  be  impossible  to  avoid  alkalies.  They 
are  expediently  prescribed  in  the  succeeding  formula : 

B; .      Magnesia,  calcined, 

Sodium  bicarbonate, aa     10. o  ^iiss 

Menthol, 2.0  gr.  xxx. 

Mix  thoroughly. 

SiG. — One-half  teaspoonful  pro  re  nata,  followed  by  ^  iij  water. 

It  is  not  rational  to  give  purgatives,  because  they  irritate  the  in- 
flamed mucosa;  calomel  is  the  only  drug  of  this  nature  that  can 
safely  be  given,  but  not  before  the  fermenting  stomach  contents  have 
been  removed  by  emesis  or  lavage.  To  effect  purgation  before  the 
stomach  is  emptied  exposes  the  intestine  to  infection  from  the  septic 
mass  forced  through  it.  Persistent  vomiting  may  call  for  special 
treatment;  here,  morphin  hypodermically,  mustard  plasters  to  the 
epigastrium,  and  small  pieces  of  ice  will  be  sufficient.  •  A  singular 
case  of  very  exhausting  and  persistent  vomiting  was  in  my  practice 


434  ACUTE   GASTRITIS. 

relieved  by  bismuth  salicylatis  gr.  x;  cocain  hydrochlorate,  gr.  ^; 
menthol,  gr.  ij ;  aqua  camphor.,  f  S  ss.  M.  Every  two  hours  until 
relieved.  Vomiting  of  this  character  is  bound  to  bring  on  collapse. 
It  is,  fortunately,  a  rare  complication,  but  must  be  met  energetically 
if  it  develops.  In  concluding  the  medicinal  treatment,  we  desire  to 
refer  to  a  successful  therapeutic  measure  which  does  not  properly 
belong  under  this  heading,  because  it  is  not  medicinal,  but  mechanical. 
This  consists  of  evacuating  the  stomach  with  the  tube,  and  imme- 
diately thereupon  disinfecting  it  by  washing  it  out  with  a  solution  of 
the  following  composition: 

R.     Thymol, 0.5  gr.  viij 

Boric  acid, 16.  ^ss 

Warm  water, 1000.  one  quart.   M. 

SiG. — Lavage  fluid. 

The  water  during  lavage  must  be  used  quite  warm  and  the  antisep- 
tic not  used  until  the  plain  water  runs  out  clear.  Use  one  pint  or  500 
CO.  at  a  time.  Catch  up  the  outflowing  antiseptic  fluid  and  ascertain 
that  it  approximates  one  pint ;  a  few  ounces  retained  will  not  do  harm. 
Vomiting,  as  a  rule,  ceases  entirely  after  this.  Six  hours  later  wash 
out  the  colon  by  large  enemata  of  ten  per  cent,  solution  of  boric  acid, 
no  matter  whether  the  patient  has  di^-rrhea  or  constipation.  If  diar- 
rhea exist,  it  is  absolutely  rational  to  effect  the  removal  of  the  putre- 
fying colonic  contents  by  large  enemata  (given  in  the  knee-chest  pos- 
ture), and  if  constipation  exist,  the  stagnation  of  feces  certainly  ag- 
gravates the  symptoms  by  increasing  flatulence  and  abdominal  pres- 
sure. If  there  is  any  therapeutic  measure  in  addition  to  abstinence 
from  food  that  merits  confidence,  it  is  this  mechanical  cleansing  of 
stomach  and  colon.  Rare  cases  of  high  temperature  may  need  spe- 
cial therapeutic  measures  for  the  fever.  Here,  also,  drugs  must  be 
avoided  and  the  temperature  reduced  by  sponging  with  cold  water  or 
the  cold  bath. 

In  case  the  appetite  fails  after  the  attack,  or  there  is  protracted 
weakness  with  timidity  and  aversion  to  food,  the  following  tonic  will 
prove  useful: 

R.     Strychnin,  sulphatis, 0.021         gr.  y^ 

Acidi  hydrochlorici  dilut., 12.  f  .^  "j 

Elixir  gentianse, q.  s.  ad  mis.,  192.  fo^J-        •^^• 

SiG. — One  tablespoonful  diluted  with  two  ounces   H.fi  three-quarters  of  an  hour 
before  "meals,  through  a  glass  tube. 

Forms  of  acute  gastritis  associated  with  copious  vomiting  of  bile 
are  frequently  seen  in  our  latitude  and  termed  "bilious  attacks." 


PHLB;GM0N0US   or   purulent   gastritis.  435 

There  is  no  liver  disease  associated  with  the  attacks,  and  they  are 
generally  brought  on  by  errors  in  diet  and  mental  strain. 


PHLEGMONOUS    OR    PURULENT    GASTRITIS— SUPPURATIVE    IN- 
FLAMMATION OF  THE  STOMACH— GASTRIC  ABSCESS. 

This  is  a  very  acute,  fatal,  and,  fortunately,  very  rare  affection  of 
the  gastric  walls,  apparently  set  up  by  an  invasion  of  pyogenic  cocci. 
It  is  a  purulent  inflammation  invariably  originating  in  the  submucous 
connective  tissue,  and  from  here  extending  to  the  mucosa,  ^iegler 
("Lehrbuch  d.  allgem.  u.  spec.  path.  Anat.,"  1887,  Bd.  11,  S.  516)  de- 
scribes large  numbers  of  streptococci  occurring  partly  free  in  the  tis- 
sues and  partly  in  the  protoplasm  of  the  cells.  In  case  the  serosa  is 
invaded,  the  disease,  as  a  rule,  produces  a  general  fatal  peritonitis  by 
perforation,  unless  an  infection  of  the  peritoneum  is  prevented  by  an 
agglutination  with  adjacent  organs.  We  have  seen  but  one  case  of 
this  sort;  it  was  not  diagnosed,  but  discovered  at  the  autopsy.  It 
had  followed  ulcus  carcinomatosum  of  the  pylorus.  The  submucosa 
and  muscularis  mucosae  were  pushed  apart  by  numerous  miliary  ab- 
scesses. (vSee  Hemmeter  and  Ames,  "N.  Y.  Med.  Record,"  Sept., 
1897,  "A  Case  of  Phlegmonous  Gastritis,"  etc.)  We  submit  an  excel- 
lent drawing  showing  four  small  abscesses  forcing  apart  the  fibers  of 
the  muscularis  mucosae.  As  far  as  one  is  able  to  judge  from  the  liter- 
ature on  this  subject,  the  disease  is  inevitably  fatal,  running  most 
always  an  acute,  rarely  a  subacute,  course.  Ewald  {loc.  cit.,  p.  303) 
has  seen  only  one  case,  and  that  at  the  clinic  of  his  teacher,  Frerichs. 
It  occurs  much  oftener  in  men  than  in  women;  of  41  cases,  33  were 
men  and  eight  women.  In  a  report  by  Glax  ("Die  Magenentziin- 
dung.,"  "Deutsche  med.  Zeit.,"  1884,  No.  3)  it  is  stated  that  but  51 
cases  had  been  observed  up  to  that  time.*  Most  authors  who  have 
had  experience  with  the  disease  distinguish,  first,  an  idiopathic  pri- 
mary purulent  gastritis,  the  etiology  of  which  is  obscure;  and, 
secondly,  a  secondary,  metastatic,  phlegmonous,  or  purulent  gastritis, 
which  is  an  accompaniment  or  a  sequence  of  other  infections,  such  as 
pyemia,  puerperal  fever,  anthrax,  typhus,  or  variola.  Anatomically, 
one  may  distinguish  a  diffuse  and  a  circumscribed  purulent  inflam- 
mation of  the  submucosa ;  the  latter  is  spoken  of  as  a  stomach  abscess. 

Etiology. — The  direct  cause  of  the  rarer  idiopathic  phlegmonous 

*  We  have  collected  the  entire  literature  on  the  subject  of  phlegmonous  gastritis,  which 
is  appended. 


436  PATHOLOGY    OP   PHLEGMONOUS    GASTRITIS. 

gastritis  is  unknown.  The  predisposing  causes  may  be  the  same  as 
stated  under  the  etiology  of  simple  gastritis.  The  direct  causes, 
judging  from  anatomical  specimens,  are  undoubtedly  bacterial  inva- 
sions of  the  submucosa,  principally  by  pyogenic  cocci  that  find  portals 
of  entry  through  lesions  in  the  superficial  epithelium  of  the  stomach, 
such  as  occur  in  most  gastric  diseases,  especially  in  so-called  exfolia- 
tion in  carcinomata  and  old  ulcers,  or  after  trauma  caused  by  fish- 
bones, seeds,  foreign  bodies,  etc.  Ziegler's  bacteriological  {loc.  cit.) 
studies  have  already  been  mentioned.  The  secondary  metastatic 
phlegmonous  gastritis,  which  seems  most  frequent,  is  that  following 
puerperal  fever,  and  owes  its  origin  to  localization  in  the  stomach  of 
the  specific  organisms  producing  the  fundamental  disease.  What- 
ever they  may  be,  it  is  self-evident  that  only  an  enfeebled  organ  is 
liable  to  such  an  inflammation,  since  pyogenic  cocci  can  not  resist  the 
action  of  the  free  HCl  of  the  gastric  juice. 

Pathological  Anatomy. — The  diffuse  inflammation  rarely  in- 
vades all  parts  of  the  stomach  with  the  same  intensity,  even  if  the 
whole  organ  is  involved.  The  pyloric  portion  is  generally  invaded 
more  than  the  others;  toward  the  cardia  the  inflammatory  process  is 
less  and  less  marked,  while  the  esophagus  is  rarely  attacked.  The 
submucous  layer  is  most  extensively  altered;  on  cross-section  it  is 
swollen,  showing  an  edematous,  purulent,  or,  at  times,  a  bloody  infil- 
tration. From  here  the  inflammation  spreads  along  the  interglandu- 
lar  tissue  between  the  glandular  tubules,  effecting  fine  or  larger  per- 
forations in  the  mucosa,  which  may  assume  a  sieve-like  appearance. 
Pus  wells  up  through  these  cribriform  perforations  as  out  of  a  swollen 
sponge.  It  may  occur  that  the  mucosa  is  lifted  from  the  submucosa 
by  accumulations  of  pus.  Rokitansky  has  described  a  case  in  which 
the  mucosa  was  only  strikingly  anemic,  otherwise  unaltered.  Mac- 
leod  ("Lancet,"  1887,  vol.  11,  p.  1166)  describes  a  gastric  abscess  in 
which  mucosa  was  said  to  be  unaltered. 

Toward  the  deeper  portions  of  the  engorged  layers  the  process 
spreads  along  the  bundles  of  muscular  fibers  in  the  muscularis,  which 
undergo  fatty  degeneration,  and  show  infiltration  with  pus  cells  and 
proliferation  of  nuclei.  The  serous  or  peritoneal  layer  may  also  be 
lifted  from  the  subserous  or  muscular  layers,  and  perforation,  as  a 
rule,  rapidly  follows  inflammation  of  this  layer.  Circumscribed  ab- 
scesses, which  must  be  differentiated  from  the  diffuse  inflammation, 
are  usually  small,  varying  from  the  size  of  a  hazelnut  to  that  of  a  goose 
e:gg  (Leube,  loc.  cit.).     On  cutting  into  the  swollen  elevated  areas  of 


PLATE  VI. 


D 


,uir 


Phlegmonous  Gastritis  in  the  Sequence  of  Ulcus  Carcinomatosum.     Section 

Showing  the  Lower  Part  of  the  Mucous  Coat  with  the  Ends  of  Some 

of    the    Gastric    Glands,    the    Muscularis    Mucosae,  and    a 

Small   Portion   of  the  Upper   Part  of  the  Submucosa. 

— {^Original   observation    ft'om  the  Author'' s    Clinic.^ 

Objective,  one-sixth.     Eyepiece,  one  inch.      Stained  with  hematoxylon  and  orange  G. 
Magnification  about  320  diameters. 

In  all  sections  the  small  round-cell  infiltration  is  well  marked,  the  cells  chiefly  filling 
up  the  muscularis  mucosae  and  invading  the  lower  portion  of  the  mucous  coat.  In  the 
muscularis  mucosae  these  cells  are  aggregated  into  a  number  of  small,  circular,  dense 
masses  (/9),  niiiiary  abscesses,  between  which  they  are  but  little  less  numerous.  The 
fibers  of  the  muscularis  mucosae  have  been  widely  separated  by  these  cells.  Few  cancer 
cells  are  to  be  seen  in  this  portion  of  the  tissue,  but  in  one  place  (C)  they  are  found  plug- 
ging completely  a  small  vessel.  In  the  upper  part  of  the  submucosa  a  few  of  the  cancer 
cells  can  also  be  seen  {D\. 


PHLEGMONOUS    GASTRITIS.  437 

mucous  membrane,  the  abscess  is  found  in  the  submucosa,  but  may 
extend  through  the  muscularis  to  the  serosa. 

Symptomatology. — The  symptoms  are  very  much  like  those  of  a 
very  intense  simple  acute  gastritis;  the  pain  of  gastric  phlegmon  is 
not  materially  increased  by  change  of  position  or  pressure.  There  is 
very  rarely  any  vomiting  of  pus  in  diffuse  purulent  gastritis.  Gastric 
abscess  may  be  attended  by  copious  vomiting  of  pus,  after  which  a 
tumor  that  may  have  been  palpable  before  may  become  much  smaller, 
or  disappear  entirely;  this  phenomenon  might  be  significant  for  the 
diagnosis  of  gastric  abscess  if  it  were  not  for  the  fact  that  pus  tumors 
of  the  neighboring  organs  sometimes  break  through  into  the  stomach 
and  cause  the  same  symptoms.  The  fever  reaches  io4°-io5°  F.,  the 
patient  being  aware  from  the  outset  that  he  is  very  seriously  ill.  The 
sensorium  is  much  disturbed  by  great  restlessness,  headache,  insom- 
nia, delirium.  To  the  symptoms  of  acute  gastritis  those  of  a  sudden 
peritonitis  may  be  added  at  any  time. 

Diagnosis. — The  important  conditions  for  diagnosis  are  the  pain, 
vomiting,  meteorism,  fever,  diarrheas,  and  general  phenomena.  The 
pain  is  localized  in  the  epigastrium,  but  is  said  to  have  been  absent  in 
some  cases.  The  emesis  is  always  present,  and  consists  of  bile,  mucus, 
and  food  debris;  in  diffuse  purulent  gastritis,  pus  has  not  been  no- 
ticed in  the  vomit,  which  strongly  resembles  so-called  peritoneal 
vomiting. 

The  fever  is  very  high,  and  the  temperature  curve  is  said  to  re- 
semble those  of  pyemic  fevers,  with  marked  remissions  and  exacerba- 
tions. Tympanites  and  diarrhea  are  more  frequent  than  constipa- 
tion. Other  symptoms  are :  rapid,  compressible  pulse,  cold  periph- 
eral parts,  hurried  respiration,  thirst,  and  a  much-coated  tongue. 
The  course  of  gastric  abscess  is  not  characteristic,  and  Leube  states 
("Spec.  Diagnose  d.  inneren  Krankheiten,"  S.  237)  that  the  diagnosis 
is  a  matter  of  chance.  The  attack  may  resemble  a  circumscribed 
peritonitis  or  one  of  the  various  perigastric  inflammations  or  ab- 
scesses; according  to  Ewald  {loc.  cit.)  it  may  so  mimic  abscess  of  the 
spleen  or  left  lobe  of  the  liver  that  a  differential  diagnosis  is  abso- 
lutely impossible.  Deininger  ("Deutsches  Archiv  f.  klin.  Med.,"  Bd. 
XXIII,  S.  268)  held  that  high  fever,  constant  and  intense  gastralgic 
pain  that  is  not  increased  on  movement,  and  increased  resistance 
in  the  epigastrium,  should  be  sufficiently  characteristic  to  justify  a 
diagnosis.  These  symptoms,  however,  occur  also  in  above  conditions 
referred  to  by  Ewald.  Chvostek  ("Wiener  Klinik,"  1881,  and 
29 


438  INI^ECTIOUS   GASTRITIS. 

"Wiener  med.  Presse,"  1877,  Nos.  22-29),  however,  seems  to  have 
made  the  diagnosis  in  one  of  his  cases.  The  case  reported  by  the 
author  ("A  Case  of  Phlegmonous  Gastritis,"  etc.,  by  Hemmeter  and 
Ames,  "New  York  Medical  Record,"  loc.  cit.)  was  not  diagnosed 
antemortem.  The  condition  of  diffuse  suppurative  gastric  inflam- 
mation had  followed  an  ulcus  carcinomatosum,  which  had  been  recog- 
nized and  suGcessfuU}^  treated  as  a  simple  ulcer  by  my  associate,  Dr. 
E.  ly.  Whitney,  fourteen  months  before  death  occurred.  When  there 
is  probability  of  diffuse  or  circumscribed  phlegmonous  gastritis,  the 
exploratory  puncture  with  an  aspirating  needle,  or  the  exploratory 
incision,  is,  in  our  opinion,  justifiable.  In  Penzoldt  and  Stintzing's 
new  "Specielle  Therapie  innerer  Krankheiten, "  volume  iv,  page  446, 
von  Heinecke  gives  suggestions  for  the  operative  treatment  of  phleg- 
monous gastritis. 

Prognosis  is  almost  always  unfavorable,  especially  in  the  diffuse 
form.  After  the  circumscribed  form  and  evacuation  of  the  abscess, 
several  clinicians  have  reported  recoveries  (Deininger,  loc.  cit.,  Glax, 
loc.  cit.,  Karchmann,  loc.  cit.,  also  Buckler,  "Idiopathic  Phlegmon. 
Gastritis,"  "Bayerisch.  Aerztliches  Intelligenzblatt,"  1880,  No.  37), 
but  it  is  impossible  to  confirm  whether  they  were  really  gastric  ab- 
scesses. Dittrich  has  found  cicatrices  in  the  submucosa  pointing  to 
the  possibility  of  healing. 

Treatment. — If  a  diagnosis  could  be  made,  it  seems  to  me  that 
these  cases,  the  diffuse  as  well  as  the  circumscribed  forms,  had  best 
be  treated  surgically.  Under  the  existing  difficulty,  the  treatment 
can  be  only  symptomatic  and  limited  to  relieving  pain  by  hypodermic 
injections  of  morphin,  applications  of  ice, — ice-bag  to  the  stomach, 
ciiished  ice  by  the  mouth.  To  counteract  collapse,  wine  enemata 
and  hypodermic  injections  of  strychnin  may  be  recommended.  Medi- 
cines by  the  mouth  are  worse  than  useless. 

INFECTIOUS  GASTRITIS. 
{^Gastritis  infectiosa,  diphtheritica,  crouposa,  mycotica,  parasitaria.) 
As  Penzoldt  correctly  remarks  {loc.  cit.),  every  gastritis  is  to  a  cer- 
tain extent  infectious ;  for  this  reason  a  number  of  authors  reject  the 
conception  of  infectious  gastritis  as  a  separate  and  distinct  disease, 
lyebert  {loc.  cit.)  and  Oser  (article  on  Gastric  Diseases  in  "Eulen- 
burg's  Realencyclopadie,"  second  edition,  volume  xii,  p.  410)  be- 
lieve that  there  is  a  characteristic  infectious  gastritis  peculiar  to  itself. 
Boas  ("Spec.  Therapie  d.  Magenkrankh.,"  p.  6)  is  of  the  opinion  that 


MYCOTIC   GASTRITIS.  439 

there  is  a  form  of  acute  gastroenteritis,  well  characterized  clinically, 
which  differs  from  simple  gastritis  by  the  gravity  of  the  symptoms, 
and  particularly  the  course  of  the  fever,  so  that  it  merits  separate 
consideration.  Ewald,  on  the  other  hand,  holds  that  there  is  no 
sufficient  specificity  of  inflammatory  processes  affecting  the  stomach 
for  establishing  a  separate  class  of  infectious  gastritis.  Fleiner,  Pen- 
zoldt,  and  Einhorn  give  no  separate  consideration  to  infectious  gastri- 
tis. Those  that  establish  a  separate  category  for  this  affection  class 
under  this  head  all  gastric  invasions  by  infectious  germs,  so  that  all 
forms,  as  remarked  before,  are  to  a  certain  extent  infectious. 

The  symptoms  are  said  to  be  very  similar  to  acute  simple  gastritis, 
and  therefore  require  no  further  description.  The  course  is  more 
protracted,  as  it  may  last,  according  to  Boas,  three  to  ten  days. 
According  to  Lebert  {loc.  cit.),  some  cases  may  have  fever  for  two  to 
three  weeks.  In  this  case  the  Widal  method  {loc.  cit.)  should  be  made 
use  of  under  such  conditions  to  distinguish  them  from  enteric  fever. 
Gaffky  ("Deutsch.  Med.  Wochenschr.,"  1892,  No.  14)  gives  an  ac- 
count of  severe  gastroenteritis  in  three  persons  who  drank  the  un- 
boiled milk  of  a  cow  affected  with  hemorrhagic  enteritis.  He  be- 
lieves that  the  infecting  germ  was  a  particularly  virulent  type  of  the 
bacillus  coli  communis.  A  number  of  similar  mass  epidemics  are  on 
record  (Husemann,  "Deutsch.  med.  Wochenschr.,"  1889,  S.  960)  that 
tend  to  strengthen  the  conception  of  a  special  infectious  gastritis. 
There  seems  no  necessity  as  yet  for  a  separate  classification  of  this 
kind;  the  subject  is  still  too  hypothetical  to  be  ranked  as  equal  in 
importance  with  other  well-characterized  forms  of  gastritis.  The 
diagnosis,  prognosis,  and  treatment  are  said  by  Boas  to  be  the  same 
as  for  acute  simple  gastritis. 

Diphtheric  gastritis  is  a  rare  affection,  occurring  not  only  as  a 
sequence  to  laryngeal  and  pharyngeal  diphtheria,  but  also  as  an 
accompaniment  to  pyemia,  septicemia,  puerperal  fever,  scarlatina, 
variola,  endocarditis,  ulcerosa,  typhus,  etc.  The  disease  is,  as  a  rule, 
not  discovered  until  the  autopsy  is  made,  and  for  that  reason  has  more 
of  a  pathological  than  clinical  interest. 

Mycotic  Gastritis. — When  the  vitality  of  the  mucosa  and  the 
secretion  of  hydrochloric  acid  have  been  reduced,  suppressed,  or  de- 
stroyed, certain  pathogenic  fungi  are  known  to  invade  the  mucosa, 
producing  ulcerations  and  necrosis. 

Most  of  these  mycotic  gastritic  inflammations  can  not  be  recog- 
nized during  life  as  such.     Among  those  that  have  been  described 


440  MYCOTIC   GASTRITIS. 

are  the  anthrax  gastritis,  produced  by  spores  or  bacilli  of  antlirax 
lodging  in  tlie  mucosa  or  submucosa,  and  giving  rise  to  inflammation, 
ulceration,  and  necrosis. 

Sidney  Martin  observed  a  case  of  anthrax  of  the  anterior  wall  of 
the  stomach  at  Guy's  Hospital;  the  primar}"  infection  was  in  the  left 
cheek,  where  a  malignant  pustule  developed  ('  'Journal  of  Pathology 
and  Bacteriology^-,"  vol.  i). 

Gastritis  caused  by  the  favtis  fungtcs  (achorion  Schonleinii)  has 
been  reported  by  Kundrat  ("Ueber  Gastro-enteritis  Favosa,"  "  Wien. 
med.  Blatter,"  1884,  Xo.  49).  The  case  was  that  of  a  drunkard 
whose  gastric  mucosa  was  predisposed  by  alcoholic  chronic  gastritis; 
he  had  favus  universalis,  and  in  the  stomach  and  intestines  the  fungi 
had  caused  diphtheric  inflammations,  with  fibrous  exudations,  ulcera- 
tion, and  sloughing;  death  was  caused,  it  appears,  by  a  terminal 
colitis. 

The  thrush  fungus  (German,  Soor;  Latin,  Oidium  albicans)  has 
been  reported  as  setting  up  a  mycotic  gastritis;  in  some  cases  the 
stomach  alone  appeared  infected,  throat  and  esophagus  being  intact. 

The  yeast  fungus  (toruls  or  saccharomyces  cerevisiae),  sarcinae,  the 
common  molds  (peniciLLiuni  glaucum  and  mucor)  and  various  schi- 
zomycetes  occur  in  the  gastric  contents  and  set  up  irritation  of  the 
mucosa :  not  by  direct  invasion,  it  appears,  but  by  the  toxic  products 
of  the  fermentation  which  they  cause. 

Sarcinae,  according  to  Hiihne,  do  not  bring  about  any  fermenta- 
tion. 

Mnier's  interesting  inA'estigations  concerning  the  bacterial  flora  of 
the  mouth  have  been  referred  to  on  page  66.  Orth,  in  the  first 
volume  of  his  excellent  text-book  ("Specielle  pathol.  Anatomic," 
Bd.  I,  p.  704),  describes  an  interesting  bacterial  invasion  near  an  old 
chronic  gastric  ulcer  which  had  largely  healed.  At  several  places 
there  were  grayish,  bran-like  incrustations,  partly  adherent,  which 
anatomically  had  to  be  designated  as  diphtheric.  In  the  scabs  or 
crust,  and  in  the  deeper  parts  of  the  mucosa,  and  partly  lodged  dis- 
tinctly in  lymph  vessels,  were  numerous  bacilli  that  had  some  mor- 
phological resemblance  to  those  of  anthrax;  this  supposition  could 
not,  however,  be  confirmed  by  cultures.  The  case  was  complicated 
by  the  fact  that  a  fatal  hemorrhage  had  occurred  from  a  ver\'  small 
arteriole  at  a  place  where  only  a  ver}^  tiny  defect  in  the  mucosa  was 
observable.  In  the  immediate  neighborhood  of  this  defect  the  bacilli 
were  found  also,  but  not  in  suflicient  numbers  to  attribute  to  their 


PLATE  VII. 


Bacterial  Invasion  of   Gastric  Epithelium.     From  a   Case   of  Diphtheric 
Gastritis. — [^Hemmeter. ) 


TOXIC    GASTRITIS.  44 1 

destructive  agency  the  tearing  of  the  arteriole,  which  was  not  aneu- 
rysmatic. 

Orth  then  refers  to  the  bacilkis  gastricus,  or  pol5''sporus  brevis  of 
Klebs  ("Ueber  Infectiose  Magenaffectionen,"  "Allgemein.  Wien. 
med.  Zeit.,"  1881,  Nos.  29  and  30),  which  this  pathologist  claims  to 
have  found  free  in  the  lumen  of  the  glands  as  well  as  between  the  cells 
of  the  glands  and  the  tunica  propria ;  there  was  also  an  interglandular 
small  round-cell  infiltration. 

Bottcher  ("Dorpater  med.  Zeitschr.,"  1875,  p.  184)  also  defended 
the  view  that  gastric  ulcers  are  in  part  due  to  mycotic  and  bacterial 
invasions.  Unfortunately,  Klebs'  and  Bottcher's  statements  have 
not  been  confirmed  by  later  investigators. 

Animal  parasites  are  also  on  record  for  producing  gastritis.  C. 
Gerhardt  ("Magenkatarrh  durch  lebende  Dipterenlarven, "  "Jenaer 
med.  Zeitschr.,"  Bd.  iii,  S.  522)  gave  an  account  of  acute  gastritis 
set  up  by  larvae  (maggots)  of  diptera,  a  class  of  insects  of  which  the 
common  fly,  the  flea,  etc.,  are  examples.  The  eggs  of  these  larvae 
were  said  to  have  been  swallowed  with  raspberries.  Meschede  (' '  Kin 
Fall  von  Erkrank.  durch  im  Magen  weilende  lebende  Maden,"  "Vir- 
chow's  Archiv,"  Bd.  xxxvi,  S.  300)  reports  gastritis  caused  by  mag- 
gots eaten  with  cheese.  Senator  reported  gastritis  set  up  by  living 
maggots  of  the  common  fly,  which  occurred  in  the  mouth  and  stomach 
("Berlin,  klin.  Wochenschr.,"  1890,  No.  7);  the  same  observation 
was  made  by  Hildebrandt  ("Berlin,  klin.  Wochenschr.,"  1890,  No. 
19).  Fermaud  observed  a  case  of  gastritis  and  gastralgia  caused  by 
an  earthworm  ("Journal  de  Med.  Practique  de  Paris,"  1836,  tome 
VII,  p.  57).  It  is  known  also  that  ascarides  and  tape-worms  may 
reach  the  stomach  in  rare  cases  and  give  rise  to  severe  inflammations, 
which  may  subside  at  once  as  soon  as  the  offending  parasite  is  vomited. 

Toxic  Gastritis  (Gastritis  Venenata). — This  form  of  acute  gastric 
inflammation  is  caused  by  poisons  or  corrosive  chemical  bodies.  The 
poisons  that  have  been  taken,  either  by  mistake  or  with  suicidal  in- 
tentions, are  mercuric  chlorid  or  corrosive  sublimate,  phosphorus, 
arsenic,  chloroform,  creasote,  potassium  chlorate,  oxalic  acid,  nitro- 
benzol,  carbolic  acid,  the  concentrated  inorganic  acids,  sulphuric, 
hydrochloric,  and  nitric  acids;  the  caustic  alkaline  hydroxids  in 
strong  solution,  and,  furthermore,  alcohol  in  all  its  forms,  and  some 
substances  used  as  medicines  (see  etiology  of  acute  gastritis),  particu- 
larly croton  oil,  antimonium  and  potassium  tartrate  (tartar  emetic) ; 
also  ammonia. 


442  TOXIC   GASTRITIS. 

The  pathology  will  necessarily  vary  considerably,  as  it  is  not  only 
dependent  upon  the  kind,  but  upon  the  quantity  and  concentration 
of  the  poison ;  and  also  upon  the  circumstance  whether  the  poison  is 
taken  on  a  full  or  an  empty  stomach,  as  food  and  drink  dilute  the 
drugs.  There  may  be  only  a  slight  superficial  inflammation,  or  a 
very  penetrating  corrosive  effect  involving  the  entire  gastric  wall  and 
even  leading  to  perforation.  Different  drugs  produce  different  effects 
upon  the  mucosa.  Phosphorus,  arsenic,  antimony,  and  alcohol  pro- 
duce, in  excessively  large  toxic  doses,  a  milky,  yellowish-white,  or 
opaque  appearance.  The  epithelia  of  the  alveoli  of  the  tubular  glands 
are  partly  in  a  state  of  mucoid  degeneration,  partly  finely  granulated, 
cloudy,  and  showing  fatty  degeneration;  the  same  is  the  case  with 
the  secreting  cells.  The  tissue  between  the  cells  is  crowded  with  a 
small  round-cell  infiltration.  In  this  condition  auto-digestion  by  the 
gastric  juice  may  cause  peptic  ulcers — i.  e.,  when  the  poisons  are  not 
taken  sufficiently  strong  to  effect  ulceration  or  to  destroy  secretion. 

Dilute  acids  and  alkalies  induce  the  clinical  picture  of  a  simple 
acute  gastritis ;  while,  in  concentrated  form  the  same  agents  cause  a 
deeply  penetrating  necrosis,  formation  of  crusts  and  intense  reactive 
inflammation  v/ith  serous  infiltration,  suppuration,  and  blood  extra- 
vasation. The  scabs  or  crusts  show  different  colors  with  different 
corrosives.  Under  the  effect  of  sulphuric  acid  they  are  black;  of 
nitric  acid,  yellow ;  of  alkalies,  brown ;  of  copper  salts,  green  or  blue ; 
of  silver  salts,  black.  Dislodgment  of  these  crusts  leads  to  fatal 
bleeding,  tearing  of  the  serosa,  or  perforation,  with  peritonitis. 
Oxalic  acid  is  said  to  produce  a  jelly-like,  semitransparent  swelling. 
Ammonia  causes  a  pustular  inflammation. 

Symptoms. — After  taking  the  poison  there  is  generally  an  inde- 
scribably severe  pain,  intolerable  burning,  and  vomiting  which  in- 
creases the  pain  and  at  times  causes  fainting.  The  vomit,  as  a  rule, 
contains  blood  or  bloody  mucus.  The  thirst  is  great.  There  is  most 
frequently  diarrhea  containing  blood.  Severe  general  symptoms 
follow:  small,  very  fast  pulse;  jactitation;  delirium.  In  case  much 
of  the  poison  has  reached  the  general  circulation,  hematogenous 
icterus,  petechiae,  albuminuria,  and  hematuria  may  follow.  Death 
may  follow  in  a  few  hours  or  a  few  days  from  collapse ;  or  later  by 
perforation  peritonitis.  Even  if  the  patients  are  tided  over  the  first 
period  of  acute  gastric  symptoms,  they  may  die  later  from  hemor- 
rhage when  the  scabs  and  crusts  are  sequestrated,  or  by  sequelae — i.  e., 
stenosis  of  the  esophagus,  cardia,  pylorus,  or  atrophy  of  the  mucosa. 


TOXIC    GASTRITIS.  443 

The  diagnosis,  after  learning  the  history  of  the  case,  will  not  be 
difficult.  One  should  not  fail  to  make  a  thorough  examination  of  the 
mouth  and  throat,  where  the  corrosive  effect,  if  any,  will  be  evident. 

The  prognosis  of  severe  toxic  gastritis  is  necessarily  grave;  if  not 
from  the  direct  poisoning  or  first  destructive  effect  of  the  drug,  cer- 
tainly from  the  severe  secondary  effects. 

The  treatment  will  vary  with  the  nature  of  the  poison.  In  recent 
poisoning  with  strong  acids,  magnesia  usta  (calcined)  should  be  given 
as  soon  as  possible.  If  no  drug-store  is  near,  chalk,  or  even  powdered 
lime,  which  can  be  scraped  from  the  wall,  should  be  given.  When- 
ever possible,  the  stomach-tube  should  be  used  at  once  for  all  poison- 
ing of  recent  date. 

Boas,  Fleischer,  and  Pick  advise  that  the  tube  should  not  be  used 
in  severe  acid  or  caustic  alkali  poisoning,  because  of  the  danger  of 
perforating  the  stomach.  In  six  cases  of  poisoning — one  with  lye 
(KOH),  two  with  oil  of  vitriol  (H2SO4),  one  with  strong  ammonia 
(NH3),  and  two  with  carbolic  acid — the  tube  was  used  immediately 
after  the  patients  reached  the  hospital.  As  such  cases  run  great  dan- 
ger of  a  corrosive  perforation,  we  have  personally  used  the  tube  and 
let  the  patient  take  his  chances,  which  were  better  in  these  cases  than 
in  those  where  the  tube  was  not  used.  About  250  c.c.  of  water,  with 
sodium  bicarbonate  in  case  acids  have  been  taken,  or  vinegar  in  case 
of  alkalies,  is  indicated  to  dilute  and  combine  with  the  destructive 
agent  present.  Lemon  juice  will  also  answer  for  the  alkaline  caus- 
tics. In  all  other  poisonings  the  stomach-tube,  or,  if  convenient,  the 
pump,  should  be  used  as  soon  as  possible,  and  the  stomach  washed  out 
thoroughly.  The  approved  antidotes  should  be  given  (freshly  pre- 
pared hydrated  oxide  of  iron  for  arsenic,  etc.),  that  will  be  found  in 
various  text-books  on  toxicology  and  therapeutics  (H.  A.  Hare's 
system;  H.  C.  Wood;  Tauder  Brunton;  Binz,  Schmiedeberg ;  Pen- 
zoldt  and  Stintzing's  system,  vol.  iv).  After  carbolic  acid  ingestion, 
wash  out  the  stomach,  and  then  pour  in  250  c.c.  olive  oil.  In  all  cor- 
rosive poisoning  cases  the  pouring  in  of  olive  oil  or  molten  vaselin, 
after  neutralization  and  washing  out,  will,  if  possible,  diminish  the 
corrosive  effect.  When  not  too  much  acid  or  alkali  has  been  taken, 
the  subnitrate  of  bismuth  or  subgallate  of  bismuth,  one  dram  twice  a 
day,  swallowed  with  oil,  will  favor  rapid  cicatrization  and  inhibit  bac- 
terial infection  of  the  necrosed,  charred  areas.  A  suspension  of  bis- 
muth subnitrate,  three  drams  to  one  pint  mucilage  and  .water,  has 
proved  advantageous  in  a  case  of  carbolic  acid  poisoning  in  our  prac- 


444  CHRONIC    GASTRITIS. 

tice;  it  was  used  in  form  of  lavage.  Another  was  healed  of  long 
standing  gastric  ulcerations  by  blowing  in  bismuth  subnitrate  and 
subgallate  through  a  stomach-tube — dry,  not  in  suspension. 

If  the  pain  is  severe,  morphin  must  be  promptly  given,  hypoder- 
mically,  in  -J  to  ^  of  a  grain  doses,  repeated  until  relief  comes.  It  is 
our  duty  to  give  relief  of  the  pain  at  any  risk,  even  if  chloroform 
anesthesia  is  required ;  for  after  the  suffering  ceases  our  efforts  to  save 
the  patient  can  be  more  easily  executed.  Nutrition  must  be  carried 
on  by  rectal  enemata  only.  By  the  mouth,  ice  is  about  all  that  is 
permissible;  it  will  tend  to  diminish  the  pain,  fever,  and  inflamma- 
tion. We  make  so  explicit  a  statement  of  treatment  because  we  had 
experience  with  two  cases  where  the  autopsy  showed  that  recovery 
might  have  been  possible  (as  not  much  sulphuric  acid  had  reached 
the  stomach)  if  the  treatment  had  been  more  heroic — i.  e.,  if  the  tube 
had  been  used  for  timely  removal  of  the  poison. 


CHAPTER  II. 
CHRONIC  GASTRITIS. 


lyittle  over  a  decade  ago  it  was  customary  to  designate  all  stomach 
diseases  that  were  not  acute,  and  that  could  not  be  diagnosed  as  dila- 
tation, ulcer,  or  carcinoma,  as  "chronic  gastric  catarrh."  We  agree 
with  Ewald  and  Penzoldt  in  the  objections  to  the  word  "catarrh," 
and  have  given  the  reasons  under  the  chapter  on  Simple  Acute  Gas- 
tritis. Even  at  the  present  day  there  is  no  absolute  uniformity  in  the 
conception  and  limitations  of  the  term  "chronic  gastritis." 

With  the  aid  of  improved  methods  of  diagnosis,  particularly  such 
methods  as  permit  of  an  exact  study  of  the  various  gastric  functions, 
the  so-called  gastric  neuroses  have  been  recognized  as  separate  and 
distinct  diseases;  formerly  they  were  believed  to  be  symptoms  of 
chronic  gastritis.  This  chronic  inflammation  of  the  mucosa  affects 
all  the  important  functions,  although  one  or  the  other  of  these  is 
generally  most  involved.  There  are  observed  many  variations  in 
kind  and  intensity  of  disturbed  function,  from  a  trivial  reduction  of 
secretion  of  gastric  juice  or  interference  with  motility,  to  complete 
suppression  of  glandular  activity  and  pronounced  insufficiency  of 
peristalsis.     There  are  two  pathological  processes  inseparable  from 


TREATMENT    OF    CHRONIC    GASTRITIS.  445 

every  chronic  gastritis;  these  are:  degeneration  and  desquamation 
of  the  glandular  cells,  and  infiltration  of  connective  tissue.  Bearing 
in  mind  these  conditions,  we  may  distinguish  two  main  types  of 
chronic  gastritis :  first,  the  hypertrophic ;  and,  secondly,  the  atrophic. 
The  hypertrophic  form  consists  of  proliferation  of  the  connective 
tissue,  leading  to  change  of  form  and  folding  or  warty  elevations  of 
the  mucosa  ("etat  mammelone,"  or  polyposis).  The  result  of  this 
process  is,  first,  either  complete  destruction,  or,  secondly,  cystic  de- 
generation of  the  glands.  A  grayish-brown,  or,  in  places,  a  dark 
brown,  color  is  peculiar  to  this  swollen  and  proliferated  mucosa, 
which  is  covered  with  an  adherent,  gray  coating  of  mucus. 

The  atrophic  form  consists  of  contraction  of  the  connective  tissue, 
loss  of  epithelium,  and  more  or  less  complete  destruction  of  the  glands ; 
in  rare  instances,  superficial  ulcerations.  The  mucous  membrane  is 
much  thinned  out,  very  smooth,  and  of  a  grayish-white  or  pale  slate- 
gray  color.  If  this  process  attacks  the  muscularis  and  submucosa,  it 
may  cause  atrophy  of  the  muscle  fibrils,  with  or  without  thickening 
of  the  entire  gastric  wall  due  to  new  formation  of  connective  tissue. 
Then,  again,  we  may  meet  with  a  genuine  hypertrophy  of  the  muscu- 
laris, particularly  at  the  pyloric  portion,  or  in  the  pylorus  itself  (hy- 
perplastic stenosis  of  the  pylorus).  The  lumen  of  the  stomach  in 
these  forms  may  show  a  normal  capacity ;  or  it  may  be  mucli  dimin- 
ished in  size  by  connective-tissue  thickening  of  the  gastric  walls  and 
subsequent  contraction.  This  process  is  known  as  "gastric  cirrho- 
sis" (Brinton).  By  French  writers  it  is*termed  '  'hypertrophic  sclero- 
sis of  the  stomach"  (Hanot  and  Gombauldt,  "Archiv  de  Physiol.," 
IX,  p.  412;  also  Dubey,  "Gazette  Hebdomin.,"  1883,  p.  198),  and  it 
may  reduce  the  normal  capacity  to  160  c.c.  (L-eube,  Penzoldt).  Or, 
again,  the  capacity  is  much  increased  by  a  dilatation  in  consequence 
of  chronic  gastritis  and  hypertrophic  pyloric  stenosis.  So  the  ana- 
tomical picture  may  present :  (a)  atrophy  of  the  mucosa  with  wasting 
of  the  peptic  glands  and  of  the  muscularis;  thinning  of  the  entire 
gastric  wall,  and,  very  frequently,  dilatation ;  or,  on  the  other  hand, 
(6)  inflammatory  hyperplasia  of  the  layers  of  the  stomach,  with  exces- 
sive connective-tissue  proliferation  (cirrhosis  ventriculi) ;  hypertro- 
phic pyloric  stenosis ;  atrophy  of  the  glandular  layer  and  sometimes 
of  the  muscularis.*     This  form  may  lead  to  marked  reduction  of  the 

*See  Hemmeter  and  Stokes,  "Chronic  Hypertrophic  Gastritis,"  etc.,  "Jubilee 
Memorial  Volume,"  on  occasion  of  twenty-fifth  anniversary  of  Doctorate  of  Prof. 
William  H.  Welch,  M.D.,  Johns  Hopkins  University',  1900. 


446  CHRONIC    GASTRITIS. 

lumen  if  the  hypertrophy  invade  all  layers  uniformly.  But  if  it  attack 
the  pyloric  portion  only,  there  may  be  a  dilatation.  Both  forms 
produce  grave  disturbances  of  motility,  secretion,  and  absorption. 

The  cause  of  the  elevated,  warty,  or  polypoid  projections  of  the 
glandular  layer  is  to  be  sought  in  the  fact  that,  in  certain  forms  of  the 
disease,  the  mucous  layer  grows  much  more  rapidly  than  the  sub- 
mucous la3^er,  bringing  about  a  rough,  wrinkled,  mammillated  surface 
that  has  been  described  as  "gastritis  polyposa,"  and  by  some  French 
writers  is  termed  "etat  mammelone"  (see  Orth,  "Specielle  pathol. 
Anat.,"  Bd.  i,  p.  709).  A  number  of  Germans  describe  a  variety  of 
special  forms  of  chronic  gastritis  under  the  names  of  "saurer  Katarrh" 
(sour,  or  acid,  gastritis),  "Schleimkatarrh"  (slimy,  or  mucous,  gas- 
tritis), also  termed  "gastritis  atrophicans,"  and  a  simple  chronic 
gastritis,  or  "einfacher  Katarrh."  All  of  these  terms  are,  unfor- 
tunately, chosen  and  unscientific  because  they  are  artificial.  The 
so-called  "saurer  Katarrh"  is  not  a  gastritis  at  all  (Ewald),  but  a 
neurosis  of  secretion:  a  hyperacidity,  the  result  of  secondan,^  irrita- 
tion of  the  mucosa. 

Etiology. — Chronic  gastritis  is  a  wide-spread  disease,  occurring  in 
all  stations  of  life,  but  most  frequently  among  the  poorer  classes, 
where  the  quality  of  the  food  may  be  so  inferior  as  to  keep  the  stom- 
ach in  a  state  of  constant  irritation.  All  the  numerous  injurious  in- 
fluences which  arise  from  a  defective  and  inappropriate  diet  have 
been  referred  to  under  the  head  of  the  pathogenesis  of  acute  gastritis. 
It  may  evolve  from  the  acute  or  subacute  form,  where  the  mucosa 
has  been  damaged  by  the  altered  circulation  and  its  resistance  to 
disease  lessened.  It  may  arise  from  all  processes  that  lead  to  venous 
congestion  of  the  stomach— t.  e.,  affections  of  the  organs  of  the  por- 
tal system,  especially  of  the  liver  and  spleen ;  it  may  also  be  caused 
by  diseases  of  the  heart.  There  are  certain  conditions  which  may 
bring  about  a  chronic  gastritis  by  effecting  alterations  in  the  composi- 
tion and  structure  of  the  blood ;  among  these  are :  anemia,  chlorosis, 
scrofula,  secondary  aneraias  following  typhus  and  typhoid  fevers,  the 
exanthemata,  pregnancy,  tuberculosis,  diabetes,  gout,  and  nephritis. 
Irritating  substances  brought  continuously  in  contact  with  the  mu- 
cosa, either  from  without  or  within, — i.  e.,  from  the  blood, — are  be- 
lieved to  cause  the  disease.  Ewald  states  that  it  may  result  from 
direct  local  irritation  of  alterations  in  the  mucosa  itself,  such  as 
cicatrices  and  neoplasms.  Our  experience  is  that  in  the  vicinity  of 
such  structural  changes  preexisting  in  the  mucosa  there  is  indeed  a 


ETIOLOGY.  447 

gastritis  observed,  but  it  partakes  mostly  of  an  acute  or  subacute 
type.  Among  the  most  pronounced  causes  of  the  frequency  of 
chronic  gastritis  are:  defective  chewing  and  insalivation,  hurried 
eating  and  swallowing  of  large  pieces  of  food,  putrefaction  of  the 
mouth  from  carious  teeth,  or  the  manifold  forms  of  stomatitis  and 
gingivitis,  and,  in  this  country,  excessively  hasty  eating,  with  the 
abuse  of  ice-water  at  meals  and  of  tobacco  and  alcoholic  liquors  be- 
tween meals.  The  majority  of  American  people  residing  in  cities 
live  under  commercial  and  social  customs  pernicious  to  the  digestive 
organs.  Foremost  among  these  conditions  are  the  high  mental  pres- 
sure evoked  by  the  demands  of  business,  the  constant  worry  and  ner- 
vous tension  caused  by  force  of  competition,  the  anxiety  to  get  rich 
rapidly  by  straining  all  mental  and  physical  powers ;  all  these  things 
bring  about  a  hasty  nervous  manner  of  taking  food.  Chewing  is  a 
process  which  most  business  men  execute  in  a  perfunctory  manner 
only,  allowing  no  time  for  insalivation.  If  it  were  possible,  they  would 
gulp  the  food  down  dry ;  as  it  will  not  go  down  that  way,  it  is  washed 
down  with  ice-water.  Tobacco  juice  is  responsible  for  much  of  this 
disease;  also  condiments  used  habitually  (pepper,  ginger,  mustard, 
horse-radish),  and  the  habitual  use  of  drugs  (arsenic,  silver  salts, 
iodids). 

Chronic  gastritis  is  most  frequent  among  habitual  consumers  of 
alcoholic  liquors.  From  what  was  said,  under  acute  gastritis,  of  the 
experimental  production  by  Ebstein  of  this  disease  with  alcohol, 
the  frequency  of  the  chronic  form  among  the  devotees  to  Bacchus  and 
Gambrihus  is  very  intelligible.  As  Ewald  correctly  remarks,  the  dis- 
ease may  be  classified  among  those  in  which  the  patient's  indiscre- 
tions play  a  very  important  role.  But,  as  most  persons  treat  their 
stomachs  badly,  and  neither  eat  with  proper  mastication  nor  are  able 
to  resist  culinary  temptations,  gastritis  is  one  of  the  "best  nourished" 
and  most  prevalent  diseases  in  the  world.  "Indigestion  is  the  re- 
morse of  a  guilty  stomach,"  says  Ewald;  and  F.  Albin  Hoffmann 
("Vorlesungen  iiber  allgemeine  Therapie,"  Leipzig,  1885)  expresses 
a  sentiment  that  deserves  to  be  an  apothegm :  "Jeder  Mensch  bat  den 
Magen  den  er  zu  hahen  verdient"  ("every  one  has  the  stomach  which  he 
deserves").  It  is  not  intended  here  to  do  injustice  to  a  large  number 
of  sufferers  from  weak  stomachs  who  take  the  greatest  possible  care 
to  avoid  d3^spepsia,  and,  nevertheless,  are  liable  to  acute  or  chronic 
gastritis.  The  etiology  explains  why  the  male  sex  is  much,  more  fre- 
quently affected  than  the  female. 


448  CHRONIC    GASTRITIS. 

The  Pathological  Anatomy. — The  changes  are,  as  in  the  acute 

form,  most  pronounced  in  the  pyloric  region,  and  from  here  extend 
to  the  fundus.  The  alterations  of  structure  occurring  in  the  course 
of  chronic  gastritis  present  varying  pictures,  according  to  the  dura- 
tion of  the  disease.  In  the  later  stages  the  variations  are  considera- 
ble, since,  at  this  period,  the  connective-tissue  changes  may  at  one 
time  incline  to  inflammatory  hyperplasia ;  at  another,  may  show  an 
atrophic  character ;  again,  either  the  mucosa  or  submucosa  only,  or, 
in  other  instances,  the  deeper  layers  may  be  involved,  with  alternat- 
ing intensity  and  extent.  The  inflammatory^  process  is  not  at  all 
limited  to  mucoid  degeneration  and  desquamation  of  the  surface 
epithelium,  but  preeminently  affects  the  glandular  elements  and 
interstitial  tissue,  whence  it  attacks  the  deeper  layers  of  the  gastric 
wall.  In  early  stages  there  is  a  general,  diffuse  redness,  due  to  h}^- 
peremia ;  in  later  stages  this  color  exhibits  a  peculiar  pigmentation, 
which  first  assumes  a  bluish  or  brownish  shade,  and  finally  gets  to  be 
of  a  dirty  red-brown,  or  slate-gray,  or  both.  This  pigmentation  is 
generally  limited  to  the  pyloric  region,  but,  in  spots,  it  may  be  spread 
over  other  sections  of  the  inner  surface  of  the  stomach.  The  color  is 
caused  by  blood  pigments  which  have  become  stored  .up  in  the  cells 
and  interstitial  tissue;  also  by  blood-corpuscles  that  have  left  the 
vascular  channels  and  undergone  pigment  metamorphosis  during  the 
long-standing  chronic  hyperplasia.  This  pigmentation  must  not  be 
confounded  with  postmortem  discoloration. 

Inflammatory  Hyperplasia. — In  this  form  the  gastric  mucosa  may 
either  preserve  the  velvety  appearance  peculiar  to  the  normal  inner 
surface  of  the  contracted  stomach,  or  it  may  be  covered  with  irregular 
warty  projections,  and  exhibit  immense  development  of  the  pyloric 
"plicae  villosae."  This  is  due  generally  to  inflammatory  infiltration 
of  the  int-erglandular  and  subglandular  connective  tissue,  but  particu- 
larly to  the  same  process  occurring  in  the  connective-tissue  ridges 
("Leisten")  existing  between  the  vestibular  entrances  to  the  gland- 
ducts  ("Vorraume"  of  the  Germans),  or  peptic  duct  alveoli,  as  we 
prefer  to  call  them.  If  these  hypertrophic  hyperplastic  processes  are 
confined  to  circumscribed  areas,  they  may  assume  exaggerated  de- 
grees, forming  polypoid  proliferations  which,  as  a  rule,  are  attached 
by  broad  bases;  in  consequence,  however,  of  connective-tissue  con- 
traction, they  may  also  occur  pedunculated.  In  this  way  papillo- 
matous excrescences  may  be  developed  which  project  into  the  lumen 
of  the  stomach  (Orth,  "Gastritis  Polyposa,"  loc.  cit.,  p.  710).     When 


PATHOLOGY    OF    CHRONIC    GASTRITIS.  449 

the  submucosa  is  attacked  with  inflammatory  infiltration  and  new 
formation  of  connective  tissue,  the  loose  tissue  is  first  transformed 
into  one  m^ch  richer  in  cells,  subsequently  into  a  tougher,  more  in- 
elastic layer,  resulting  naturally  in  a  much  reduced  movabUity  of  the 
mucosa  upon  its  substratum.  When  this  chronic  process  results  in 
cicatricial  contraction  in  the  hyperplastic  submucous  tissue,  it  may 
lead  either  to  partial,  localized  change  of  form,  or  to  a  more  or  less 
general  uniform  contraction  ("Schrumpfung,"  "cirrhosis  ventriculi "  ; 
"linitis  plastica,"  Brinton).  In  the  pyloric  portion  this  process  may 
lead  to  stenosis.  Frequently,  the  muscularis  also  is  hypertrophied, 
as  a  consequence  of  the  chronic  inflammation  transmitted  through 
the  submucosa.  This  muscular  hypertrophy  is  most  pronounced  at 
the  pylorus.  The  localization  at  the  pylorus  of  the  maximal  inten- 
sity of  the  inflammatory  process  in  the  mucosa,  submucosa,  and  the 
muscularis,  makes  the  origin  of  a  pyloric  stenosis  in  consequence  of 
chronic  gastritis  intelligible.  This  kind  of  stenosis  is  usually  spoken 
of  as  benign  (hyperplastic  stenosis),  in  contradistinction  to  the  malig- 
nant stenosis  of  carcinoma  (Hemmeter  and  W.  R.  Stokes,  loc.  cit.). 

Much  diversity  of  opinion  exists  concerning  the  origin  of  the  etat 
mammelone  ("mammelon  "  means  the  nipple  of  the  mammary  gland). 
Frerichs  held  that  it  was  due  to  accumulations  of  fat  in  the  mucosa, 
and  inflammatory  hyperplasia  of  its  contained  lymph-follicles.  Rind- 
fleisch  maintained  that  a  greater  growth  of  the  mucosa  than  of  the 
submucosa  was  the  cause.  Ziegler  explained  the  mucosa  polypi  by 
proliferation  of  the  submucosa.  Ebstein  assumed  an  inflammatory 
hyperplasia  of  the  tissue  between  the  glands.  Jones  assigned  as  a 
cause  an  excessive  contraction  of  single  bundles  of  the  muscularis 
mucosae.  Undoubtedly,  this  gastritis  polyposa,  with  its  mamme- 
lonated  appearance,  may  be  formed  by  a  great  diversity  of  processes. 

Inflammatory  Atrophy. — The  progressive  plastic  character  of  the 
inflammation  just  depicted  may  lead  to  retrograde  metamorphosis 
before  it  has  progressed  very  far ;  in  some  cases  it  may  not  develop  at 
all,  but  the  disposition  to  break  down  and  atrophy  may  start  early  in 
the  disease.  These  atrophic  changes  are  most  marked  in  the  glandu- 
lar elements,  and  may  be  limited  to  these.  Sometimes  the  inflamma- 
tions of  the  mucosa  and  gland-cells  have,  from  the  outset,  a  degen- 
erative tendency,  and  no  hypertrophy  or  hyperplasia  enters  into  the 
anatomical  picture.  The  surface  columnar  epithelium  and  the  cylin- 
drical epithelium  of  the  vestibular  alveoli  fall  prey  to  a  mucoid  degen- 
eration and  desquamation.     The  epithelial  cells  of  the  peptic  glands 


450  CHRONIC    GASTRITIS. 

> 

undergo  fatty  degeneration.  During  this  atrophy  the  mucosa 
changes  to  a  thin,  smooth,  pigmented,  or  slate-gray  membrane.  This 
atrophy  may  be  limited  to  the  mucosa,  while,  at  the  sarne  time,  hy- 
pertrophic changes  go  on  unhindered  in  the  submucosa  and  muscu- 
laris ;  again,  the  atrophy  may  extend  to  the  latter  layers,  and  bring 
about  a  wasting  of  all  gastric  strata.  This  last  condition  was 
formerly  designated  "tabes  of  the  stomach"  (the  "phthisis  ventri- 
culi"  of  Rokitansky).  Under  these  irreparable  atrophic  states 
anomalies  in  the  gastric  volume  may  develop,  but  dilatation  is  here 
more  frequent  than  contraction. 

Atrophy  of  the  stomach  may  occur  without  preceding  chronic 
gastritis.  It  then  appears  as  a  simple  degenerative  process,  and 
follows  severe  anemic,  cachectic  states,  and  also  grave  infectious  dis- 
eases and  poisonings. 

When  confronted  with  cases  of  gastric  atrophy,  with  absence  of 
hydrochloric  acid,  the  ferments,  and  enzymes,  and  coexistent  anemia, 
it  is  sometimes  very  difficult  to  decide  as  to  the  primary  causative 
disease.  In  these  cases  it  is  well  to  bear  in  mind  that  anemias,  even 
those  of  a  grave  pernicious  character,  may  be  a  consequence  of,  or 
rather  secondary  to,  atrophy  of  the  gastric  mucosa  which  has  ex- 
tended to  the  intestinal  mucosa.  Our  countryman,  Austin  Flint, 
was  the  first  to  call  attention  to  the  relation  between  anemia  and 
atrophy  of  the  gastric  glands.  In  i860  ("American  Medical  Times," 
i860)  he  expressed  the  opinion  that  some  cases  of  obscure  and  pro- 
found anemia  are  dependent  upon  degeneration  and  atrophy  of  the 
glands  of  the  stomach.  (Further  contributions  of  Flint  to  this  sub- 
ject are  to  be  found  in  the  "New  York  Medical  Journal,"  March,  1871, 
and  in  his  "Principles  and  Practice  of  Medicine,"  p.  477,  Philadel- 
phia, 1 88 1.)  Since  Flint's  publications,  cases  have  been  reported  by 
Fenwick  ("The  Lancet,"  1877,  July  7th,  et  seq.);  Ouinke  ("Volk- 
mann's  Samml.  klin.  Vortrage,"  No.  100,  case  b);  Brabazon  ("The 
British  Medical  Journal,"  1878,  July  27th);  Nothnagel  ("Deutsch. 
Archiv  f.  klin.  Med.,"  Bd.  xxiv,  p.  353);  Bartels  ("Berlin,  klin. 
Wochenschr.,"  1888,  No.  3);  Scheperlen  ("Nordisch.  Medic.  Arkiv," 
1879,  Bd.  XI,  No.  3);  Osier  ("Atrophy  of  the  Stomach,  with  the 
Clinical  Features  of  Progressive  Pernicious  Anemia,"  "American 
Journal  Med.  Sciences,"  1886,  No.  4).  Rosenheim  reported  two 
similar  cases  which  appeared  to  be  pernicious  anemia  (' '  Berlin,  klin. 
Wochenschr.,"  1888,  Nos.  51,  52). 

Inasmuch  as  these  cases  of  atrophy  of  the  gastric  mucosa  are 


INFLAMMATORY   ATROPHY.  45 1 

« 

accompanied  by  marked  changes  in  the  blood,  signs  of  breakdown 
in  the  red  blood-corpuscles,  increase  in  the  white  corpuscles,  and 
formation  of  macrocytes  and  microcytes,  the  question  may  arise 
whether  pernicious  anemia  is  really  an  independent  disease  or  the 
result  of  gastric  atrophy.  Atrophy  of  the  mucosa — not  secondary  to 
well-known  stomach  or  general  diseases,  but  occurring  as  a  primary 
disease — has  been  claimed  to  exist  by  Fenwick  {loc.  cit.).  Professor 
William  H.  Welch  (Pepper's  "Amer.  System  of  Medicine,"  vol.  xi,  p. 
616),  however,  was,  at  the  time  of  that  publication,  of  opinion  that 
the  existence  of  atrophy  of  the  stomach  as  a  primar}^  independent 
disease  had  not  been  established,  the  histological  examination  of 
many  of  the  cases  reported  as  such  having  been  defective.  Professor 
"W^elch  has  since  modified  his  views  on  this  subject.  From  the  state- 
ments of  some  writers  the  impression  might  be  gained  that  the  hyper- 
trophic hyperplastic  form  of  chronic  gastritis  was,  from  its  fully  de- 
veloped stage,  changed  into  the  atrophic  form.  This  would  mean 
the  total  disappearance  of  the  papillary,  polypoid  proliferations  of  the 
"etat  mammeione,"  because  the  mucosa  of  the  atrophic  form  is  very 
smooth.  According  to  Orth  {loc.  cit.,  p.  710),  this  is  very  improba- 
ble. He  is  of  the  opinion  that  the  atrophic  form  is  developed  uni- 
formly by  transformation  of  cellular  interstitial  tissue  into  contract- 
ing cicatricial  tissue,  bringing  about  thinning  of  the  mucosa  and  de- 
generation of  the  glandular  elements  without  the  intervening  features 
of  hyperplasia  above  referred  to. 

Ulcerative  processes  are  said  to  occur  (Ziegler,  loc.  cit.)  when,  in 
the  course  of  the  disease,  intense  (hemorrhagic)  inflammation  pro- 
duces necrosis  of  the  epithelium  and  submucosa,  and  its  subsequent 
"sequestration."  In  this  way  the  so-called  catarrhal  gastric  ulcers 
and  hemorrhagic  erosions  are  formed,  which  may  be  associated  with 
hemorrhage.  Cruveilhier  ("Anatomic  Pathologique  du  Corps  Hu- 
maine  ")  records  a  follicular  gastritis  in  which  ulcers  were  said  to 
originate  in  the  follicular  glandular  apparatus. 

The  ulcers  of  chronic  gastritis  are  mostly  small,  round,  or  irregu- 
larly indentate.  They  are  supposed  to  heal  and  form  flat  pigmented 
cicatrices.  Forster  asserts  that  they  may  lead  to  perforation.  Orth 
{loc.  cit.),  whose  statements  merit  confidence  because  of  his  scientific 
conseryatism,  is  of  the  opinion  that  ulcerative  processes  in  the  course 
of  chronic  gastritis  are  very  rare.  The  minute  anatomy  of  the  pro- 
cess is  that  of  a  parenchymatous  and  interstitial  inflammation.  The 
glandular  cells  are  partly  destroyed,  partly  granular,  and  partly 
30 


452  CHRONIC    GASTRITIS. 

shriveled  up ;  differentiation  between  the  chief  (Hauptzellen)  and  the 
parietal  cells  (Belegzellen)  is  impossible.  In  many  places,  especially 
in  the  pyloric  region,  the  ducts  have  lost  their  regular  order  of  lying 
alongside  of  one  another,  and  show  atypical  manifold  ramification 
like  glove  fingers.  Isolated  glands  become  separated  at  the  fundus 
and  appear  as  cysts  at  the  border  of  the  submucosa ;  these  are  either 
empt}^,  with  a  smooth  lining  membrane,  or  are  filled  with  the  remains 
of  glistening  hyaline  cuboidal  epithelium.  There  is  an  abundant 
small-celled  infiltration  which  is  especially  marked  near  the  surface  of 
the  mucous  membrane;  the  cells  lie  between  the  glands,  and,  in 
places,  push  their  ducts  far  apart.  In  the  hyperplastic  form  we  see 
processes  of  connective  tissue  which  proceed  upward  between  the 
glands  from  the  submucosa,  like  the  branches  of  a  tree.  The  free 
surface  of  the  glandular  layer  is  covered  with  a  film  of  mucus  inclosing 
many  leukocytes  and  nuclei  (Ewald).  The  superficial  layer  of  the 
epithelium  of  the  mucosa  is  loosened,  and  can  be  separated  in  adher- 
ent shreds,  which  may  sometimes  be  found  in  the  wash-water  after 
lavage  of  the  stomach.  In  sections  one  can  readily  see  the  mouths 
of  the  glandular  ducts  and  the  surrounding  epithelium.  The  epithe- 
lial cells  of  the  vestibular  alveoli  ("Vorraum")  are,  for  the  greater 
part,  filled  with  a  pale  mucous  mass,  which  projects  sharply  against 
the  lumen  without  any  inclosing  membrane,  as  described  by  Kupffer 
in  the  normal  stomach.  Ewald  has  been  able  lo  study  this  and  the 
following  conditions  in  specimens  which  were  obtained  immediately 
after  death,  or  from  living  persons  after  resection  of  the  pylorus.  In 
the  conditions  (to  be  described  presently)  of  gastritis  mucosa  or  muci- 
para,  this  mucoid  degeneration  may  be  observed  to  extend  to  the 
base  of  the  glands,  so  that  in  place  of  the  ordinary  chief  and  oxyntic 
cells,  we  find  only  cells  in  the  most  varied  stages  of  mucoid  degenera- 
tion (see  Fig.  33).  This  condition  is  especially  marked  in  the  pyloric 
region.  Some  isolated  cells  may  be  found  which  are  still  intact,  the 
mucus  filling  only  a  small  part  of  them,  while  the  rest  of  the  cell  is 
occupied  by  granular  protoplasm  and  a  large  nucleus.  In  others, 
the  mucus  occupies  the  greater  part  of  the  cells,  and  crowds  the  pro- 
toplasm and  the  flattened  nucleus  against  its  base.  In  still  others, 
the  cell  membrane  has  ruptured,  and  the  mucus  has  escaped  into  the 
lumen  of  the  duct  of  the  gland,  where  it  has  been  precipitated  in 
streaks  by  the  alcohol.  This  gives  rise  to  very  delicate  figures  which 
resemble  a  row  of  horseshoes  with  their  openings  toward  the  lumen  of 
the  gland.     That  this  is  really  mucus,  and  not  the  isolated  formation 


SYMPTOMATOLOGY. 


453 


of  vacuoles  as  described  by  Stohr  and  vSachs,  is  easily  proved  by  the 
reaction  with  acetic  acid,  and  the  grayish  color  with  hematoxylin. 
Ewald  emphasizes  the  fact  that  these  features  are  found  only  where 
the  mucous  membrane  has  been  placed  in  alcohol  while  still  warm ;  in 
old  tissues  he  has  never  met  them.     Thus  there  is  a  mucoid  degenera- 


FiG.  33. — Atrophy  and  Vacuolization  of  Glandular  Elements— Mucoid  Degeneration 

OF  Peptic  Cells— Increase  of  Interstitial  Connective  Tissue— Small 

Round-celled  Infiltration. 

In  some  places  the  glandular  elements  have  disappeared,  leaving;  empty,  circular  spaces.     From 
a  case  of  chronic  (alcoholic)  gastritis  (this  fragment  was  found  in  the  wash-water). 


tion  of  the  protoplasm  of  the  cells,  which  extends  deep  down  into  the 
fundus  of  the  gland. 

Symptomatology. — As  a  general  rule,  the  onset  of  gastritis  can 
not  be  determined  with  certainty,  because  it  develops  very  gradually 
and  insidiously,  either  as  a  continuation  of  acute  gastritis  and  of  other 
diseases,  or  as  an  independent  disease;  the  initial  symptoms,  not 
being  very  pronounced,   are  generally  ignored.     Only  the  sudden 


454  CHRONIC    GASTRITIS. 

aggravation  caused  by  dietetic  errors,  and  other  injurious  influences, 
lead  to  the  conclusion  that  a  serious  disease  is  present.  The  clinical 
picture  varies  considerably,  although  the  signs  of  a  disturbed  diges- 
tion, as  indicated  by  absence  of  appetite,  eructation,  nausea,  vomit- 
ing, pressure  and  fullness  in  the  gastric  region,  repeat  themselves  in 
various  cases ;  first  one  symptom  and  then  another  will  manifest  its 
presence  or  be  entirelv  absent.  Perhaps  the  most  constant  of  the 
early  symptoms  is — 

Absence  of  Appetite  (Anorexia). — Even  in  less  serious  attacks  this 
symptom,  as  a  rule,  exists,  and  may  eventuate  in  disgust  for  the  cus- 
tomary diet.  After  prolonged  fasting  the  patient  feels  that  the  stom- 
ach is  empt}^  but  there  is  no  desire  to  eat  and  no  hunger.  There  is, 
however,  a  strong  craving  for  "piquante,"  salty,  or  acid  food.  It 
seems  as  if  an  instinctive  knowledge  existed  that  the  production  of 
gastric  juice  is  depressed  and  that  the  mucosa  requires  a  stronger 
incentive  to  secretion.  Sometimes  a  slight  appetite  is,  at  rare  inter- 
vals, developed,  which,  however,  a  very  few  mouthfuls  of  food  suffice 
to  satisfy  completely.  Incidentally  the  desire  for  food  will  increase  if 
the  patients  force  themselves  to  eat;  now  and  then  bulimia — an 
intense  hunger — may  develop  at  extraordinary  times, — e.  g.,  during 
the  night, — but  this  is  more  frequent  in  the  neurosis  of  hypersecre- 
tion, which  was  formerly  classed  as  a  gastritis.  Thirst  and  salivation 
are  frequently  increased. 

Taste. — We  have  rarely  observ^ed  a  case  of  chronic  gastritis  of  long 
standing  in  which  there  were  not  present  one  or  more  of  the  following 
complications :  Pharyngitis,  posterior  nasal  catarrh,  laryngitis,  or  a 
form  of  stomatitis  or  glossitis,  the  last  occurring  most  frequently. 
This  condition  of  the  mouth  perA^erts  taste,  rendering  it  pasty,  some- 
times distinctly  unpleasant,  acid,  bitter,  or  metallic.  The  breath  is 
frequently  offensive,  caused  by  caries  of  the  teeth  and  by  decomposi- 
tion on  and  in  the  lingual  epithelium,  and  eliciting  the  remark  that 
"food  has  no  taste."  Almost  all  foods  then  taste  alike.  Occasion- 
ally, the  breath  will  first  become  offensive  at  the  height  of  indigestion, 
one  or  two  hours  after  meals,  and  especially  so  after  ill-smelling 
eructations ;  this  is  suggestive  of  gastric  decomposition. 

Nausea  is  an  early  symptom,  generally  preceding  emesis;  it  may 
exist  by  itself  for  many  hours  without  emesis,  and  may  even  occur  on 
an  empty  stomach.  "When  it  occurs  after  eating,  it  subsides  upon 
vomiting  the  food.  The  ingestion  of  food  may  diminish  or  increase 
the  nausea,  which  is  not  alwavs  a  direct  effect  of  ingesta  or  fermenting 


THE   VOMITING    IN    CHRONIC    GASTRITIS.  455 

contents  on  the  stomach  itself.  We  have  observed  it  when  no  food 
has  been  taken  by  the  stomach  for  ten  days,  when  daily  lavage  has 
been  carried  out  and  nutrition  conducted  by  rectal  feeding.  This 
form  of  nausea  may  be  an  effect  of  intestinal  autointoxication  of  a 
severe  type,  as  these  chronic  cases  of  gastritis  are  occasionally  sub- 
ject to  "ptomain  storms." 

Eructation  is  in  all  cases  present  at  some  time.  The  gases  brought 
up  are  air  and  carbon  dioxid;  in  some  rare  instances  inflammable 
gases,  such  as  hydrogen  and  marsh-gas,  CH4,  have  been  eructated 
(Ewald,  Rupstein).  The  gases  may  be  tasteless  and  odorless,  or  may 
have  an  offensive  after-taste  of  rancid  or  bitter  character,  particularly 
when  small  portions  of  ingesta  rise  up  with  the  belching.  Sometimes 
the  contents  of  the  stomach  are  very  rich  in  organic  acids,  this  being 
most  likely  when  the  motility  and  the  secretion  of  normal  HCl  are 
suppressed.  A  very  high  total  acidity,  showing  no  free  nor  com- 
bined HCl  at  all,  will  then  be  composed  almost  entirely  of  lactic,  buty- 
ric, and  acetic  acids.  This  is  a  very  rare  occurrence  in  chronic  gas- 
tritis in  our  experience,  and,  as  a  rule,  associated  with  some  disturb- 
ance of  motility.  When  this  acid  mass  is  forced  up  into  the  esopha- 
gus during  the  eructations,  a  very  annoying  heartburn,  or  pyrosis, 
ensues,  which  seems  localized  at  various  parts  of  the  gullet  or  cardia, 
and  may  last  for  hours. 

Vomiting,  though  not  so  frequent  as  in  acute  gastritis,  nevertheless 
occurs  quite  often.  In  the  chronic  gastritis  of  drinkers  it  is  often  a 
regular  event  each  morning,  and  is  then  known  as  the  "morning 
vomit,"  or  vomitus  matutinus  (water-brash),  which  Frerichs  attrib- 
uted to  the  swallowing  during  the  night  of  saliva  and  the  secretions 
from  the  pharyngeal  catarrh.  The  morning  vomit  is  usually  alkaline, 
as  a  rule  it  inverts  starch  to  sugar,  and  gives  the  red  rhodan-kalium 
KCNS  reaction  with  chlorid  of  iron.  A  tough,  glassy,  morning  vomit 
occurs  in  some  patients  who  are  not  drinkers ;  after  severe  retching, 
the  mucus  may  be  found  tinged  with  blood.  We  have  under  obser- 
vation at  present  a  female  patient  with  chronic  gastritis,  who  vomits 
this  glassy  mucus  almost  the  moment  she  raises  her  head  from  the 
pillow  in  the  morning.  Vomiting  which  occurs  after  meals  brings 
out  food  in  a  more  or  less  partially  digested  state,  according  to  the 
duration  of  its  retention  in  the  stomach  and  the  condition  of  the  secre- 
tions. The  eructated  ingesta  are  imbedded  in  tough  mucus,  and  may 
be  in  a  state  of  fermentation.  Bile  may  form  part  of  the' admixture. 
If  the  gastritis  is  due  to  secondary  passive  hyperemia  ("Stauungs- 


456  CHRONIC    GASTRITIS. 

katarrh  ")  accompanying  hepatic  cirrhosis,  the  vomit  may  contain 
blood  from  the  rupture  of  minute  varicosities  on  the  mucosa.  The 
ejected  food  contains  organic  acids  (particularly  after  carbohydrates 
have  been  ingested),  but  no  free  acids.  We  have  been  struck  with 
the  frequency  of  the  occurrence  of  excessive  amounts  of  acetic  acid 
when  the  gastritis  has  been  set  up  by  long-standing  abuse  of  alcohol. 
Yeast  cells,  sarcinae,  and  a  large  variety  of  bacteria  may  be  present. 
With  incipient  and  not  very  grave  cases  the  ferments,  pepsin  and 
rennin,  are  yet  to  be  detected ;  but,  in  later  stages,  they  are  evident 
only  after  adding  HCl  slightly  in  excess  of  the  deficit ;  this  really  shows 
that  the  proenzymes,  not  the  perfect  ferments,  are  present.  Finally, 
pepsinogen  and  rennet  zymogen  are  absent;  and,  in  very  advanced 
forms,  even  the  mucus  will  cease  to  be  secreted.  This  last  symptom 
is  an  indication  of  the  complete  atrophy  of  the  mucosa. 

The  tongue  is  very  frequently  coated  with  a  grayish-white  deposit, 
most  marked  on  the  back  and  root  of  the  organ.  The  impressions  of 
the  teeth  are  retained  b}^  it.  At  the  edges  and  apex  the  tongue  pre- 
sents a  deeper  red  color,  with  swollen  papillae.  The  coating  may 
disappear  toward  evening,  to  reappear  in  the  morning.  Henoch 
("Klinik  der  Unterleibskrankheiten, "  Berlin,  1863,  p.  382)  holds  that 
the  appearance  of  the  tongue  is  really  not  always  a  mirror  of  the  stom- 
ach, but  that  its  condition  is  to  be  regarded  simply  as  an  index  of  the 
existing  state  of  the  oral  mucous  membrane.  Certainly  the  tongue  is 
the  more  frequent  organ  of  the  two  to  first  become  diseased,  as  it  is 
nearer  to  the  outer  world  and  its  infections  than  the  stomach.  There- 
fore, it  might  be  supposed  that  catarrhal  states  of  the  tongue,  mouth, 
and  throat  may  occur  more  frequently  as  independent  diseases,  not 
secondary  to  antecedent  diseases  involving  the  stomach.  Schech 
("Krankheiten  d.  Mundhohle  "),  in  addition  to  malformations  and 
inherited  or  acquired  defective  forms  of  the  mouth,  describes  16  dis- 
tinct diseases  of  the  human  mouth,  not  including  neoplasms,  tumors, 
and  results  of  nervous  diseases.  Seifert  (Penzoldt  und  Stintzing's 
"Handbuch  der  spez.  Therapie,"  Bd.  iv)  describes  23  mouth  dis- 
eases. Kraus  ("Erkrank.  d.  Mundhohle,"  etc.,  Bd.  xvi;  "Spez. 
Path.  u.  Therap.,"  von  Nothnagel)  describes  36  diffuse  and  22  partial 
inflammations  of  the  mouth  and  tongue.  In  the  primary  form  all 
these  arise  in  the  mouth,  and  some  occur  as  secondary  forms  in  acute 
inflammatory  conditions  of  the  digestive  tract,  particularly  after 
infectious  diseases.  We  have  paid  particular  attention  to  the  state  of 
the  tongue,  esophagus,  and  stomach  at  autopsies,  and  also  during  a 


SUBJECTIVE    SYMPTOMS.  457 

large  number  of  analyses  of  stomach  contents,  and  must  admit  that 
the  condition  of  the  tongue  is  one  of  the  most  variable  signs  in  gastric 
symptomatology.  The  cases  of  manifest  disease  of  the  stomach 
where  a  primary  disease  of  the  mouth  is  out  of  the  question  are  ex- 
tremely rare.  A  critical  review  of  the  etiology  of  gastric  diseases  can 
not  fail  to  evince  the  fact  that  the  prominent  causes  can,  and  most 
often  do,  affect  the  mouth  and  stomach  alike.  The  gastric  disorders 
in  which  the  tongue  is  most  frequently  unaffected  are  those  associ- 
ated with  little  or  no  gastric  sepsis,  i.  e.,  ulcer,  hyperacidity,  neuras- 
thenia gastrica;  whereas  in  diseases  associated  with  much  gastric 
fermentation  or  histological  changes  in  the  mucosa  that  may  extend 
to  the  mouth,  or  involve  it  through  circulatory  or  nervous  channels, 
the  tongue  is  most  often  affected.  These  diseases  are  gastritis,  car- 
cinoma, and  dilatation. 

In  reviewing  the  statements  of  most  authors  on  the  condition  of  the 
tongue,  one  can  not  fail  to  notice  a  lack  of  clearness  and  precision, 
which  doubtless  indicates  that  the  relation  between  remote  and  local 
causes  is  not  well  understood  concerning  this  matter.  A  systematic 
bacteriological  and  histological  study  of  coated  tongues  is  very  much 
needed  in  association  with  gastric  diseases.  The  attempt  to  estab- 
lish a  definite,  characteristic  condition  of  the  tongue  for  every  gastric 
disease  has  thus  far  failed.  The  extension  of  stomatitis  and  glossitis 
to  the  stomach  by  the  deglutition  of  infective  material  is  plausible. 
But  the  various  forms  of  gastric  diseases  may  also  extend  upward, 
either  by  eructations  or  direct  cellular  continuity.  Then,  again,  the 
oral  and  gastric  cavities  are  in  intimate  correlation,  and  may  mu- 
tually affect  each  other  through  the  vascular  and  complex  nervous 
channels.  Fleischer  {loc.  cit.,  p.  820)  holds  that  the  importance  of 
the  coating  of  the  tongue  as  a  sign  of  gastritis  has  been  much  over- 
rated, and  that  the  tongue  may  be  clean  notwithstanding  very  evi- 
dent chronic  gastritis,  and  may  be  coated  when  this  disease  is  absent. 
Nevertheless,  he  considers  the  frequent  coincidence  of  coated  tongue 
and  gastritis  remarkable,  but  attributes  it  to  a  concomitant  stoma- 
titis. 

General  Nutrition. — Chronic  gastritis  of  long  standing,  left  un- 
treated, will  inevitably  affect  the  general  nutrition.  As  von  Noor- 
den  repeatedly  emphasizes,  "most  dyspeptics  do  not  eat  enough," 
and  in  consequence  of  this  emaciation  ensues  to  such  a  degree  that 
even  physicians  suspect  a  grave  underlying  disease  (tuberculosis  or 
carcinoma)  where  there  is  only  a  chronic  gastritis.     The  absence  of 


458  CHRONIC    GASTRITIS. 

appetite  is  most  frequently  caused  by  a  suppression  of  secretion  of 
HCl. 

Feeling  of  pressure  and  fullness  in  the  epigastric  region  is,  in  many 
cases,  complained  of,  and  may  be  evident  on  awakening  or  develop 
after  ingestion  of  food.  The  epigastric  region  in  these  cases  is  very 
likely  to  be  arched  forward  and  outward,  and  very  sensitive  to  pres- 
sure, even  the  weight  of  the  clothes  being  annoying.  If  no  dilatation 
exists,  the  lower  border  of  the  stomach  is  found  in  its  natural  place. 
It  must  not  be  forgotten  that  a  stomach  may  be  dilated  considerably 
and  yet  the  lower  border  be  found  in  normal  position,  for  the  organ 
may  be  enlarged  upward  or  laterally,  displacing  the  diaphragm. 
Professor  J.  Schreiber,  of  Konigsberg,  has  repeatedly  called  attention 
to  the  fact  that  the  horizontal  umbilical  line  is  a  misleading  landmark 
by  which  to  judge  a  dilatation,  and  that  the  upper  border  should,  in 
all  cases  of  suspected  dilatation,  be  determined  ("Archiv  f.  Verdau- 
ungskrankh.,"  Bd.  ii,  Heft  4).  It  may  be  possible  to  ascertain  by 
palpation  whether  the  gastric  walls  are  thickened  or  not.  If  a  dilata- 
tion be  present,  there  exists,  generally,  a  stenosis  of  the  pylorus; 
more  rarely  it  is  due  to  so-called  atony.  The  feeling  of  pressure  may 
increase  to  a  constant  dull  pain,  which  should,  if  it  becomes  intense, 
lead  to  suspicion  of  carcinoma  or  ulcer.  Some  patients  with  chronic 
gastritis  suffer  during  digestion  from  an  active  peristaltic  unrest  in 
the  stomach  and  intestines,  their  attention  being  directed  to  it  by 
abdominal  rumbling  and  gurgling  (borborygmus) . 

Conditions  of  Gastric  Contents;  Secretion. — The  results  of 
microscopical  and  chemical  analysis  after  test-meals,  or  of  lavage 
water  early  in  the  morning  before  any  food  has  been  taken,  will  var}' 
according  to  the  particular  kind  of  chronic  gastritis  and  the  present 
state  of  the  disease.  Boas  recognizes,  with  regard  to  these  points, 
four  varieties  of  gastritis,  viz. :  (i)  Acida;  (2)  anacida;  (3)  mucosa; 
(4)  atrophicans.  The  separation  of  these  four  types  clinically  is 
difficult  and  has  little  practical  value.  In  my  experience  it  is  suffi- 
cient to  ascertain  whether  we  are  dealing  with  a  simple  chronic  gas- 
tritis or  one  that  has  already  advanced  to  atrophy.  It  is  of  value  to 
know  whether  the  mucosa  is  still  in  a  condition  of  inflammatory  irri- 
tation, or  whether  this  has  terminated  in  a  state  of  connective-tissue 
degeneration. 

The  establishing  of  a  separate  form  of  gastritis  mucipara,  for  in- 
stance, may  have  its  pathological  justification,  when  one  can  demon- 
strate extensive   mucoid    degeneration   of   the    mucosa,   and   when 


TYPES    OF    CHRONIC    GASTRITIS.  459 

there  has  been  an  enormous  vomiting  of  mucus  in  the  history  of 
the  case. 

Simple  chronic  gastritis  and  chronic  gastritis  mucipara  simply 
denote  differences  of  degree  of  the  same  process.  Simple  chronic 
gastritis  is  also  a  mucous  gastritis.  The  presence  of  large  amounts  of 
mucus  in  the  empty  stomach  in  the  morning  is  the  most  character- 
istic symptom  of  this  disease. 

Gastritis  Acida. — State  of  the  Secretions. — Prior  to  the  results  of 
recent  investigations,  it  had  been  uniformly  maintained  that  absence 
or  great  diminution  of  HCl  was  a  constant  symptom  of  chronic  gas- 
tritis. Boas  argues  that  there  is  a  form  of  typical  inflammation  of  the 
stomach — termed  by  him  "Gastritis  Acida  " — in  which  there  is  pres- 
ent an  increased  amount  of  mucus,  together  with  a  normal  amount 
of  acid,  or  even  superacidity  (Boas,  "Ueber  Gastritis  Acida,"  "Mit- 
theil.  d.  Naturforscher-Versamml.  in  Wien,"  1894).  Even  the  mucus 
from  the  fasting  stomach  may  turn  Congo-paper  blue. 

Gastritis  Anacida. — In  this  subdivision  free  HCl  is  diminished  or 
entirely  absent,  but  combined  HCl  is  still  present.  Kgg-albumen 
discs  are  but  slowly  digested,  or  not  at  all,  in  the  filtrate,  even  after 
addition  of  HCl.  The  difference  between  this  and  the  atrophic  form 
is  but  one  of  degree,  as  in  the  latter  all  secretion  is  lost  completely. 

Gastritis  Mucosa  or  Mucipara. — As  was  pointed  out  (page  133) 
before,  when  rhinitis,  laryngitis,  pharyngitis,  and  bronchitis  can  be 
eliminated,  large  quantities  of  mucus  in  the  gastric  contents,  as  a  rule, 
speak  for  chronic  gastritis  mucosa.  The  cases  not  forming  much 
muciis  represent  end  stages  of  the  disease — the  atrophy.  The  mucus 
formation  can  be  best  estimated  by  washing  out  the  fasting  stomach. 
There  should  be  no  difficulty  in  differentiating  gastric  mucus  from 
that  derived  from  the  respiratory  passages.  The  former  is  generally 
thin,  clear,  glassy,  stringy,  and  flowing;  the  latter  thick,  opaque, 
yellowish-gray,  and  lumpy.  In  the  washing  from  the  fasting  organ 
one  frequently  finds  the  organic,  structural  form-elements  of  the 
mucosa  minutely  described  in  the  last  chapter  and  on  page  137.  If 
these  bits  of  mucosa  are  found  at  repeated  washings,  showing  these 
elements  either  in  conglomeration  or  singly,"  there  can  be  no  doubt  of 
the  existence  of  glandular  chronic  gastritis.  Frequently  the  morning 
contents  of  the  fasting  organ  show  numerous  leukocytes.  The  con- 
tents should  be  drawn  by  expression ;  if  possible,  without  using  water. 
In  gastritis  chronica  mucipara  the  contents  may  show  a  normal 
amount  of  HCl,  or  mav  be  either  neutral  or  alkaline. 


460  CHRONIC    GASTRITIS. 

Gastritis  Atrophicans. — In  this  variety  both  free  and  combined  HCl 
are  absent,  and  the  tests  for  enzymes  and  proenzymes  are  negative. 
Milk  taken  or  poured  into  the  stomach  is  returned  mostly  in  un- 
changed condition.  Martins  and  Liittke  {loc.  cit.),  von  Noorden,  and 
others,  maintain  that  absolute  disappearance  of  pepsin  and  rennin  is 
never  seen.  From  large  clinical  experience  I  am  prepared  to  state 
that  the  end  stages  of  atrophic  gastritis  give  no  evidence  of  ferments 
in  gastric  contents  by  any  of  the  known  tests.  Nor  would  it  be  ra- 
tional to  suppose  that  in  hypertrophic  gastritis,  in  which  the  stomach 
is  converted  into  a  hyperplastic,  dense,  hard  mass  of  muscle  and 
connective  tissue,  with  no  histological  remnant  of  a  glandular  layer, 
there  should  be  any  possibility  of  the  formation  of  enzymes.  In  atro- 
phic gastritis,  more  than  in  the  other  forms,  there  are  very  character- 
istic, lancinating  pains. 

The  digestion  of  albumin  discs  or  fibrin  in  the  thermostat  is  much 
retarded,  or  may  be  wanting  entirely,  denoting  the  suppression  of  the 
secretion  of  pepsin. 

Disappearance  of  rennin  and  its  zymogen  goes  on  simultaneously 
with  that  of  pepsin.  In  cases  with  loss  of  rennin  the  zymogen  of 
this  ferment  must  be  tested  for.  Among  other  observers,  Bouveret 
("La  pepsine  etle  ferment  lab.,"  "Gaz.  Med.  de  Paris,"  1893,  No.  22) 
declares  that  the  absence  of  this  zymogen  is  an  important  criterion 
of  the  degree  to  which  the  destructive  process  has  advanced.  For 
the  same  purpose,  Jaworski  suggests  the  introduction  of  decinormal 
solutions  of  hydrochloric  acid  into  the  stomach,  to  awaken  any 
slumbering  remnants  of  proenzyme  formation  and  convert  them  into 
perfect  enzymes.  In  no  case  that  shows  the  presence  of  rennin 
zymogen  need  hope  of  complete  or  partial  restitution  be  resigned. 

Age. — This  is  preeminently  a  disease  affecting  adults,  for  the 
young  are  not  so  liable  to  abuse  their  stomachs,  or  so  subject  to 
the  manifold  factors  composing  the  etiology;  besides,  their  recon- 
structive and  compensatory  powers  are  greater.  The  majority  of 
cases  are  over  forty  years  of  age,  but  Litten  ("Zeitschr.  f.  klin. 
Med.,"  Bd.  xiv,  S.  573)  has  reported  a  case  of  eighteen  years,  and 
Einhorn  one  of  twenty-one  years.  The  case  of  Westphalen  ("St. 
Petersburger  med.  Wochenschr.,"  1890,  Nos.  37  and  38)  was,  how- 
ever, verified  by  autopsy ;  it  occurred  in  a  young  man  twenty-eight 
years  old.  We  have  had  under  our  personal  obser\^ation  since  1888 
a  young  printer,  at  that  time  in  his  twentieth  year,  whose  case 
showed  absence  of  enzymes  and  HCl,  with  much  mucus.     Numerous 


MOTOR   FUNCTIONS    IN    CHRONIC    GASTRITIS.  46 1 

leukocytes  were  evident  in  the  contents  before  food  had  been  taken. 
Although  we  have  frequently  since  analyzed  his  stomach  contents, 
no  hydrochloric  acid  or  proenzymes  have  ever  been  detected.  But 
on  several  occasions  there  appeared  fragments  of  gastric  mucosa, 
showing  glandular  atrophy  and  chronic  inflammation. 

The  condition  of  the  bowels  most  frequently  exhibits  constipation. 
Absence  of  the  antiseptic  action  of  hydrochloric  acid  favors  intestinal 
fermentation,  flatulence,  and  meteorism.  When  there  is  much  de- 
composition of  ingesta,  intestinal  irritation  will  eventually  set  in, 
accompanied  b}''  diarrhea. 

The  urine  is  rich  in  urates  and  phosphates  and  often  gives  a  strong 
indican  reaction.     The  total  acidity  of  the  urine  is  reduced. 

The  general  health  is  variable;  the  body  weight  may  either  be 
reduced  or  remain  constant  for  years;  this  last  indicates  that  the 
intestinal  digestion  is  good.  Many  changes  of  the  general  condition, 
from  good  to  bad,  and  vice  versa,  may  occur,  but  as  the  chronic  in- 
flammation progresses  there  are  marked  symptoms  of  general  dis- 
comfort and  indisposition  to  bodily  or  mental  exertion.  The  least  exer- 
tion rapidly  tires,  bringing  on  pains  in  the  limbs,  and  despite  this 
exhaustion  there  may  be  insomnia.  This  leads  to  a  depression  of 
spirit  which  may  control  the  entire  mentality,  and  brings  on  hypo- 
chondriasis and  melancholia.  This  leads  me  to  refer  to  the  psychic 
and  nervous  symptoms,  of  which  there  may  be  many,  beginning 
with  timidity  and  worry  at  every  new  symptom,  precordial  fear, 
oppression,  and  cardiac  palpitation  accompanied  by  occasional 
attacks  of  dyspnea.  The  so-called  stomach  vertigo,  first  described 
by  Trousseau,  I  have  never  observed  in  chronic  gastritis,  nor  the 
agaro phobia  {i.  e.,  terror  in  crossing  wide  and  empty  localities  alone) 
which  Fleischer  {loc.  cit.)  says  occurs  as  a  psychic  accompaniment. 
From  practical  observation  I  am  disposed  to  believe  that  these 
psychic  and  nervous  phenomena  have  been  exaggerated,  as  they 
occur  only  in  very  protracted  cases,  and  then  even  inconstantly. 

Disturbances  of  Motility. — A  great  number  of  cases  of  chronic 
gastritis  have  been  examined  at  the  University  of  Maryland  Hos- 
pital and  the  Maryland  General  Hospital,  with  regard  to  the  peris- 
talsis; and,  in  the  large  majority,  'this  has  been  found  normal  or 
slightly  exaggerated.  We  use  the  method  described  on  pages  80-83. 
Boas  declares  that  he  has  never  observed  a  dilatation  arise  from  a 
chronic  gastritis  ("Diagnostik  u.  Therap.  d.  Magenkrankh.,"  2d 
edition,  p.  21).  It  is  evident  that  stenosis  of  the  pylorus  can  occur 
which  is  not  caused  by  cicatricial  contraction  nor  by  neoplasm,  but 


462  CHRONIC    GASTRITIS. 

by  hyperplasia  of  the  muscular  sphincter  of  the  pyloric  region.  If 
a  chronic  gastritis  lasts  long  enough,  it  is  a  fair  presumption  that  it 
may  result  in  a  gastrectasia  due  either  to  atrophy  of  the  muscularis 
from  connective-tissue  invasion,  or  to  the  muscular  hyperplasia, 
producing  a  stenosis.  Boas  has  also  conclusively  shown  that  lactic 
acid  is  not,  as  a  rule,  formed  in  glandular  gastritis. 

Complications. — The  most  frequent  is  the  extension  of  the  in- 
flammation to  the  intestines.  The  frequent  association  of  chronic 
duodenitis  with  the  disease  explains  the  occurrence  of  catarrhal 
icterus,  which  is  an  extension  of  the  intestinal  inflammation  to  the 
gall-ducts.  The  results  of  chronic  gastritis  are,  in  protracted  cases 
(particularly  when  the  intestines  have  been  involved),  marked  dis- 
turbances of  nutrition  and  anemia,  which,  as  we  have  had  occasion 
to  obser^^e,  may  assume  very  serious  forms. 

The  duration  may  vary  from  several  months  to  years,  particu- 
larly if  the  patients  have  not  the  means  nor  the  will-power  to  follow 
dietetic  regime. 

Atypical  forms  of  chronic  gastritis  are  by  no  means  rare  occur- 
rences, and  sometimes  make  a  clear  diagnosis  very  difficult.  In  the 
foregoing  description  of  the  disease  the  lack  of  very  characteristic 
and  peculiar  symptoms  is  evident.  In  addition  to  this,  the  symp- 
toms of  loss  of  appetite,  pressure,  fullness,  eructation,  vomiting  of 
mucus,  may  be  absent  in  atypical  forms,  and  it  has  been  observed 
that  chronic  gastritis  may  run  its  course  in  a  latent,  undetected 
manner.  Again,  it  may  exist  under  the  manifestations  of  a  ner\"ous 
dyspepsia,  or  there  may  be  such  prominent  intestinal  symptoms  as 
to  disguise  the  gastritis. 

Diagnosis. — It  requires  careful  study  not  only  to  distinguish 
chronic  gastritis  from  other  diseases,  but  also  to  distinguish  the 
simple,  mucous,  atrophic,  and  chronic  gastritis  acida  (of  Boas)  from 
one  another.  As  a  rule,  the  primary  and  secondary  forms  can  be 
distinguished  without  much  difficulty.  Generally  speaking,  the 
diagnosis  of  chronic  gastritis  can  only  be  satisfactorily  established 
after  the  possibility  of  the  existence  of  other  affections  of  the  stomach 
has  been  excluded.  This  disease  may  strikingly  resemble  the  clinical 
pictures  of  the  gastric  neuroses,  of  ulcer,  and  even  carcinoma.  Dila- 
tation is  a  very  rare  complication,  and  therefore  not  a  confusing 
factor  in  diagnosis.  One  should  not  make  the  diagnosis  definite  at 
the  first  examination,  but  reserve  opinion  until  the  patient  has  been 
studied  during  three  or  four  visits.  It  has,  in  some  cases,  taken  a 
much  longer  time  than  that  to  obtain  satisfactory  evidence  of  the 


DIFFERENTIAL   DIAGNOSIS.  463 

disease.  The  best  evidence  is  afforded  by  repeated  microscopical  and 
chemical  examination  of  the  wash-water  and  test-meals,  and  the 
persistent  presence  of  much  mucus  in  the  empty  stomach. 

It  will  be  necessary  to  dwell  upon  the  differential  diagnosis  be- 
tween chronic  gastritis  and  the  neuroses,  ulcer,  carcinoma,  and  amy- 
loid degeneration:  The  neuroses  may  present  all  the  symptoms  of  a 
chronic  gastritis,  particularly  the  absence  of  HCl ;  but,  after  patient 
and  repeated  test-meal  analysis,  it  will  be  found  that  the  neuroses 
will  some  day  show  a  normal  and  even  excessive  amount  of  HCl. 
The  course  to  pursue  is  to  wait  for  this  evidence.  The  presence  of 
much  mucus,  epithelial  cells,  and  leukocytes  in  the  wash-water  from 
the  jejune  stomach  indicates  chronic  gastritis.  Demonstration  of 
enzymes  and  proenzymes  is  very  valuable,  as  a  normal  amount  of 
pepsin  and  rennin  (when  HCl  is  absent)  speaks  for  neurosis  and 
against  gastritis.  In  the  absence  of  HCl,  Jaworski's  method  of 
pouring  in  decinormal  HCl  should  be  used  to  stimulate  the  formation 
of  enzymes. 

In  the  incipient  stage  of  chronic  gastritis  the  enzymes  may  be 
present,  even  in  normal  amount ;  but  they  disappear  gradually  as 
the  disease  progresses.  By  the  time  the  physician  is  consulted,  the 
enzymes  are  very  much  diminished  or  entirely  absent;  this  is  an 
indication  of  an  inflammation  of  the  mucosa,  not  a  neurosis. 

The  differential  diagnosis  between  idiopathic  chronic  gastritis  and 
ulcer  is  decided  by  the  symptom  of  pain,  which  is  always  present  in 
ulcer,  and  usually  absent  in  chronic  gastritis.  The  ulcer-pain  is 
localized,  well  circumscribed,  very  intense,  and  occurs  at  definite 
times  after  partaking  of  food.  Hematemesis,  of  course,  points  to 
ulcer.  The  vomit  of  ulcer  shows  hyperacidity,  which  is,  as  a  rule, 
absent  in  gastritis.  In  atrophic  gastritis  there  may  be  lancinating 
pains,  but  they  are  diffuse  and  not  so  frequent  or  constant  as  in 
ulcer. 

From  carcinoma  the  differentiation  may  be  difficult  when  no  pal- 
pable tumor  can  be  detected.  This  is  intelligible  when  one  reflects 
that  carcinoma  is  generally  complicated  with  chronic  gastritis.  If 
a  pyloric  carcinoma  be  present,  the  most  noteworthy  symptoms 
are :  stenosis,  motor  insufficiency,  and  stagnation  of  food  with  large 
amounts  of  lactic  acid.  A  carcinoma  seems  to  strike  a  stomach 
suddenly  with  very  severe  symptoms  and  general  disturbances — 
pain,  emaciation,  and  vomiting;  whereas  chronic  gastritis  is  char- 
acterized by  slow  increase  of  the  gravity  of  symptoms,  with  alternating 
improvements  and  aggravations.     It  is  an  important  fact  that  the 


464 


CHRONIC    GASTRITIS. 


motility  is  not  disturbed  in  chronic  gastritis,  and,  therefore,  the 
stomach  rarely  contains  anything  but  mucus,  isolated  cells,  and 
leukocytes.  But  in  carcinoma  the  peristalsis  is  seriously  impeded 
from  the  onset,  and  therefore  there  must  be  stagnation,  retention, 
and  acid-fermentation.  These  products  of  retained  ingesta  occur 
even  when  there  is  no  stenosis  of  the  pylorus,  as  a  result  of  carcino- 
matous invasion  of  the  muscularis.  Gastrectasia  is  an  exceedingly 
rare  result  of  gastritis,  and  can  occur  only  from  hyperplastic  thicken- 
ing of  the  pylorus,  a  thing  seldom  reported  in  the  literature  of  this 
subject.  As  stated  before,  the  presence  of  marked  amounts  of  lactic 
acid  is  not  observed  in  gastritis,  but  in  carcinoma  its  occurrence  is 
very  frequent.  Organic  acids  are  rare  in  the  test-meals  of  gastritis, 
whereas  in  carcinoma  there  is,  as  a  rule,  an  excess  of  lactic  and  fatty 
acids  early  in  the  disease  (Boas,  loc.  cit.).  For  further  differentia- 
tion see  article  on  Carcinoma. 

Amyloid  degeneration  of  the  stomach  may  lead  to  complete 
suppression  of  the  gastric  secretion,  but  it  is  always  a  secondary 
disease,  occurring  in  the  sequence  of  chronic  suppurative  processes 
and  pulmonary  tuberculosis.  If  the  existence  of  amyloid  degenera- 
tion can  be  established  in  the  spleen,  kidneys,  or  liver,  we  are  justified 
in  considering  a  secondary  involvement  of  the  stomach  when  HCl 
secretion  has  been  proven  to  be  lost.  This  form  of  degeneration  in 
the  stomach  is,  in  my  experience,  extremely  rare. 

Synopsis  of  diagnostic  points  in  various  types  of  chronic  gastritis : 


( I )  Simple  Chronic 

Gastritis. 
Subacid  or  anacid. 


(2) ,  Chronic   Mu- 
cous Gastritis. 


(3)  Chronic  Atro- 
phic Gastritis. 

Lancinating    pains 
presentinthisform. 

(4)  Acid  Gastritis. 


Contents  of  Fast- 
ing Stomach. 


Limited  amount  of 
watery  mucus; 
leukocytes;  epi- 
tiielial  cells; 
round  cells 

Much    mucus ;    epi- 
thelial fragments. 


Empty ;  no  mucus. 


Much  mucus;  giving 
HCl  reaction. 


Acidity. 


Variable ;  free  HCl 
rarely  present,  but 
if  present,  lessened 
in  amount ;  com- 
bined HCl  present. 

At  the  beginning 
there  may  be  a 
normal  amount  of 
combined  HCl; 
later  on  the  amount 
is  low  ;  HCl  ab- 
sent;   HCl  deficit. 

HCl  absent;  HCl 
deficit ;  no  com- 
bined HCl. 


Normal  amount  HCl. 
or  hyperacidity. 


Ferments. 


Pepsin  and  rennin  pres- 
ent in  small  amount ; 
propeptone  formed  in 
the  stomach. 


Pepsin  absent ;  rennin 
absent ;  boih  proen- 
zymes present ;  ex- 
perimental digestion 
occurs  on  supplying 
the  HCl  deficit. 


No  enzymes  ;  no  pro- 
enzymes ;  no  curd- 
ling of  milk  on  add- 
ing HCl. 

Ferments  increased. 


PROGNOSIS    AND    TREATMENT.  465 

Prognosis. — Chronic  gastritis  is  a  tedious,  but  not  a  very  serious, 
affection,  as  many  cases  recover  under  suitable  treatment.  The 
prognosis  must  vary  with  the  stage  of  the  disease  as  presented,  and 
the  intelHgence  and  will-power  of  the  patient.  Patients  who  will 
study  to  avoid  further  detrimental  influences,  and  who  have  the 
determination  to  carry  out  the  dietetic  and  hygienic  management, 
will  recover.  With  incorrigible  eaters  or  drinkers,  who  retransgress 
against  their  stomachs  on  the  slightest  improvement,  permanent 
recovery  is  doubtful.  After  the  establishment  of  partial  or  com- 
plete atrophy  of  the  glandular  mucosa,  perfect  recovery  is  impossible ; 
but  as  it  is  well  known  that  a  good  state  of  general  health  may  be 
maintained  with  complete  suppression  of  the  gastric  juice,  provided 
the  intestines  still  function  normally,  atrophy  of  the  mucosa  does 
not  necessarily  imperil  vitality.  On  the  other  hand,  there  are 
numerous  well-authenticated  observations  (see  literature)  that 
demonstrate  severe  disturbances  of  nutrition,  particularly  pernicious 
anemia,  as  a  consequence  of  gastric  atrophy.  The  instances  of  com- 
plete extirpation  of  the  stomach — Brigham  in  this  country,  whose 
case  has  already  lived  longer  than  Schlatter's  case  in  Ziirich — show 
that  metabolism  and  nutrition  may,  for  a  time  at  least,  be  apparently 
normal  with  total  absence  of  the  stomach.  These  patients  remain 
under  constant  medical  control,  however.  Fenwick  (loc.  cit.)  sug- 
gests that  this  pernicious  anemia  may  be  due  to  autointoxication 
from  the  stomach.  Other  authors,  again,  hold  that  the  anemia 
may  be  the  primary  factor,  and  bring  about  the  atrophy  of  the 
mucosa.  This  entire  question  still  partakes  of  a  speculative  nature, 
since  exact  and  logical  experiments  and  deductions  are  wanting. 

Treatment. — Prophylactic  Treatment. — The  prevention  of  the  de- 
velopment of  the  disease  implies  avoidance  of  the  causes  given  under 
the  head  of  etiology  of  acute  and  chronic  gastritis.  Special  atten- 
tion should  be  directed  to  the  avoidance  of  continued  abuse  of 
alcohol.  Every  acute  gastritis,  be  it  an  independent,  idiopathic 
affection,  or  secondary  to  other  diseases,  must  be  carefully  treated 
in  order  to  prevent  its  transition  into  the  chronic  form.  Explicit 
directions  regarding  diet  and  mode  of  life  must  be  given  to  all  suf- 
ferers from  liver,  lung,  heart,  and  kidney  diseases;  also  to  diabetics, 
in  order  that  they  may  be  saved  from  secondary  gastritis,  for  dis- 
turbances of  appetite  and  impairment  of  digestive  powers  must  in- 
evitably render  the  fundamental  disease  more  serious.    • 

The  chief  predisposing  factors  to  secondary  chronic  gastritis  are 


466  CHRONIC    GASTRITIS. 

passive  congestion  and  accumulation  of  injurious  metabolic  products 
in  the  heart  muscle,  with  renal  insufficiency.  In  cases  of  cardiac  in- 
sufficiency with  threatened  passive  engorgement,  digitalis  should  be 
used  early.  One  should  not  hesitate  to  give  digitalis  on  account  of 
the  occasional  appetite-disturbing  effect  of  the  medicine,  as  this  is 
usually  transient;  an  improvement  of  the  appetite  and  of  nutrition 
in  general  will  be  observed  in  these  cases  if  the  treatment  be  con- 
tinued; we  usually  combine  it  with  large  doses  of  strychnin.  The 
passive  engorgement  of  the  mucosa  is  more  harmful  than  the  drug. 
If  it  is  noticed  in  several  attacks  that  the  gastric  symptoms  improve 
on  administration  of  digitalis,  it  is  expedient  to  give  the  remedy  at 
the  outset  of  the  slightest  disturbance  of  appetite,  since  our  ex- 
perience has  taught  us  that  this  will  unfailingly  become  aggravated 
by  delay  in  the  use  of  the  heart  tonic.  If  the  stomach  rebels  against 
the  remedy,  the  infusion  should  be  given  by  enema  into  a  rectum 
previously  cleaned  by  warm  normal  salt  irrigation,  or  digitalin 
injected  hypodermically. 

Lavage. — When  it  is  no  longer  possible  to  remove  the  causes  that 
lead  to  a  chronic  gastritis,  we  may  yet  be  able  to  remove  those  that 
maintain  or  aggravate  the  malady.  These  causes  are:  the  accumu- 
lation of  mucus,  and  the  mechanical  as  well  as  chemical  irritation  of 
the  stagnating  contents,  particularly  when  aton}^  and  hypertrophic 
stenosis  exist.  To  accomplish  this,  emetics  are  impracticable,  be- 
cause they  rarely  effect  a  thorough  cleansing,  and  may  increase 
the  inflammation  by  the  convulsive  contractions  they  excite  and  by 
their  direct  irritation.  Purgatives  are  even  more  deleterious,  for 
several  reasons:  first,  they  also  increase  gastric  irritation;  secondly, 
they  can  not  be  used  habitually;  and,  thirdly,  they  hurry  decom- 
posing masses  into  the  intestines,  thereby  precipitating  an  involve- 
ment of  this  tract  and  the  dangers  of  intestinal  putrefaction  and 
auto-intoxication.  Lavage  is  the  only  correct  procedure  in  chronic 
gastritis  whenever  increase  of  mucus,  absence  of  HCl,  decomposition, 
and  a  protracted  stomach  digestion  are  evident.  The  mucus  often 
adheres  very  tightly  to  the  gastric  walls,  since  it  only  appears,  as  a 
rule,  toward  the  close  of  the  washing.  Its  evacuation  is  facilitated 
by  allowing  the  water  to  run  in  under  high  pressure,  and  directing 
the  patient  to  change  his  position — i.  c,  lying  on  his  back,  rising  or 
turning  on  his  side — during  the  lavage;  or  by  employment  of  gastric 
massage.  The  solution  of  the  mucus  is  effectually  accomplished  by 
adding  one  tablespoonful  of  salt  and  two  tablespoonfuls  of  sodium 


DIETETIC   TREATMENT.  467 

bicarbonate  or  biborate  to  a  liter  of  warm  water.  To  disinfect  the 
stomach  after  the  removal  of  mucus  and  fermenting  ingesta,  the 
following  remedies  are  approved  aids :  Salicylic  acid,  i  :  1000 ;  thymol, 
0.5  :  1000;  boric  acid,  10  :  1000;  chloroform  water,  5  to  10  :  1000; 
shake  the  chloroform  with  the  water,  and,  after  settling,  pour  off 
the  water,  using  only  the  latter;  hydrochloric  acid,  6  :  1000;  resorcin 
resublimate,  10  :  1000;  benzol,  5  :  1000.  The  solution  must  be  pre- 
pared immediately  before  the  washing. 

The  frequency  of  the  lavage  depends  upon  the  state  of  the  stomach. 
There  may  be  cases  that  do  not  require  it  oftener  than  once  in  two 
or  three  days ;  others  require  it  twice  in  twenty-four  hours ;  usually, 
once  a  day  is  sufficient.  The  time  of  the  washing  should  be  so 
selected  that  the  exhausted  stomach  may  enjoy  the  longest  possible 
rest.  For  this  purpose  six  o'clock  in  the  evening  is  most  suitable, 
as  it  is  then  about  six  hours  after  the  main  meal  of  the  day,  and  no 
food  or  only  very  light  diet  is  taken  after  the  lavage  and  before  bed- 
time. In  other  cases  this  hour  may  be  inconvenient,  and  an  early 
hour  before  breakfast  must  be  chosen.  A  plan  useful  in  many  in- 
stances in  which  the  stomach  requires  rest  is  to  give  a  fair  breakfast 
at  9  A.  M.,  dinner  at  3  p.  m.,  no  supper,  and  lavage  at  9  p.  m.  Wash- 
ing out  the  stomach  is  advisable  only  when  there  is  much  formation 
of  mucus  and  when  there  may  be  stagnation  of  food.  In  atrophic 
or  chronic  gastritis  without  much  mucus,  frequent  lavage  is  not 
necessary.  In  these  cases  the  stomach-tube  is  recommended,  not  to 
remove  fermenting  ingesta  or  mucus,  but  to  treat  the  mucosa  directly, 
to  stimulate  its  sluggish  secretion  by  irrigating  with  decinormal 
solution  of  HCl ;  if  enzymes  are  still  to  be  detected,  common  salt  solu- 
tions are  useful  for  this  purpose  (about  one  tablespoonful  to  the 
quart).  Solutions  of  NaCl  must  not  exceed  the  strength  of  one  per 
cent.,  as  solutions  of  four  per  cent.  NaCl  check  the  HCl  secretion  and 
are  available  in  the  treatment  of  hyperacidity.  (See  "Achylia 
Gastrica.") 

Dietetic  Treatment. — In  each  case  it  is  advisable  to  give  the  patient 
a  written  diet-list,  based  upon  a  chemical  study  of  the  individual's 
digestive  power.  Sometimes  it  will  be  impossible  to  give  a  diet  at 
first  that  will  at  the  same  time  suit  the  patient's  palate  and  digestive 
power.  The  most  digestible  food  will  at  times  disagree  with  chronic 
gastrities,  and  food  which  would  seem  a  priori  very  indigestible, 
agrees  well.  A  good  plan  is  to  inquire  minutely  into  each  patient's 
accustomed  diet  and  ascertain  what  food  especially  disagrees.  At 
3' 


468  CHRONIC    GASTRITIS. 

the  beginning,  the  diet  should  be  of  a  light  kind:  one  that  makes 
but  slight  demands  upon  the  working  capacity  of  the  stomach.  As 
the  motility  is  good  in  this  trouble,  the  diet,  as  far  as  possible,  should 
be  liquid  or  semiliquid,  and  in  some  cases  four  to  six  small  meals  a 
day  are  preferable  to  three  large  ones.  In  others  it  will  be  insuring  rest 
to  the  stomach  to  give  only  two  meals  a  day,  excluding  the  supper. 
Nutritious  soups,  such  as  beef  bouillon  enriched  by  the  addition  of 
butter,  eggs,  beef -meal  or  jelly,  somatose,  or  nutrose,  are  generally 
well  borne,  but  as  a  rule  do  not  suffice  to  maintain  strength  and  body 
weight.  It  is  well  to  insist  on  slow  eating,  thorough  chewing,  and 
insalivation  as  important.  The  teeth  should  be  looked  after,  and,  if 
necessar}^  repaired,  or  artificial  ones  provided.  Should  there  be  a 
normal  amount  of  HCl  and  pepsin  secreted,  then  a  diet  rich  in  proteid 
will  be  advisable.  Suitable  articles  of  diet  are  all  white  meats,  fish, 
and  eggs,  properly  prepared ;  which  means  that  the  roast  or  broiled 
meats,  even  after  they  are  on  the  table,  must  be  very  finely  divided 
on  the  plate  before  placing  in  the  mouth.  Light  vegetables  are 
permissible  in  form  of  purees,  viz. :  potatoes  mashed  in  milk,  peas 
or  beans  driven  through  a  sieve,  spinach,  etc.  When  the  HCl, 
although  present,  is  considerably  reduced,  the  diet  will  be  similar; 
but  spices  and  well-salted  food  are  more  adapted.  If  the  secretion 
is  completely  suppressed,  it  is  not  expedient  to  greatly  restrict  the 
diet,  as  these  patients  are  more  liable  to  suffer  from  inanition.  The 
greatest  care  is  to  be  employed  in  the  preparation  of  the  food,  which 
must  be  presented  in  an  appetizing  and  finely  divided  form.  AH 
meats  and  fish  must  be  prepared  in  the  steam  broiler,  and,  if  needed, 
they  should  be  previously  minced  and  then  reformed  into  any  de- 
sirable shape,  held  by  a  supporting  substance  such  as  experienced 
cooks  are  familiar  with,  generally  consisting  of  bread-crumbs,  eggs, 
salt,  and  butter.  Milk,  if  it  agrees  well,  is  a  valuable  adjunct  to  the 
diet,  and  even  if  not  well  digested,  or  if  there  is  an  aversion  to  it, 
should  be  surreptitiously  added  to  soups,  chocolate,  rice,  sago, 
gelatins,  and  farinaceous  foods.  When  it  is  thus  mixed  with  other 
foods  it  is  generally  very  well  digested,  and  adds  to  their  nourishing 
quality.  Von  Mehring  has  recommended  a  chocolate  (Kraftchoco- 
lade)  which  contains  20  per  cent,  of  fat;  it  is  ver>^  palatable  and 
usually  causes  no  digestive  distress.  W^hen  there  is  emaciation,  we 
give  small  amounts  of  alcohol,  upon  the  authority  of  Chittenden's 
experiments  that  alcohol  up  to  three  per  cent,  favors  proteolysis  and 
amylolysis,  and  is  a  fat-sparer.     If  we  are  sure,  from  test-meals,  that 


CONSTIPATION    IN    CHRONIC    GASTRITIS.  469 

there  is  no  gastric  fermentation, — and  according  to  our  experience 
there  rarely  is  in  chronic  gastritis, — we  recommend  the  genuine 
Oporto,  Malaga,  or  imported  Hungarian  Tokay  wines.*  When  it 
it  evident  that  the  gastritis  was  caused  by  bacchanalian  excess,  it  is, 
naturally,  a  good  plan  to  exclude  alcohol  as  far  as  possible.  Indeed, 
when  the  emaciation  is  not  marked,  or  when,  after  a  trial,  the  collec- 
tive symptoms  appear  to  become  worse,  alcohol  is  best  avoided. 
There  are,  however,  cases  of  distinct  alcoholic  gastritis  in  which, 
after  well-observed  test-meals,  the  proteolysis  is  carried  on  better 
when  wine  is  taken,  f  The  wines  we  have  recommended  have  not 
only  a  stimulating,  but,  on  account  of  their  large  percentage  of 
grape-sugar,  a  nutritive  value.  This  grape-sugar  will,  however,  in- 
crease the  lactic  acid  formation  if  it  be  already  present.  In  this 
last  case  a  standard  champagne — Mumm's  Extra  Dry,  "Roederer," 
Piper-Heidsick — is  preferable.  Beer  and  claret  are,  according  to 
our  experience,  rarely  well  borne,  and  frequently  augment  gastric 
distress.  In  cases  of  marked  anorexia  a  palatable  dilution  of  brandy 
or  whisky,  taken  half  an  hour  before  meal-times,  very  often  pro- 
duces an  appetite.  The  so-called  "Angostura  Cocktail"  is  some- 
times useful  to  sufferers  from  anorexia,  but  must  not  be  allowed  to 
alcoholic  cases.  The  physiological  reasons  for  the  administration 
of  alcohol  are  explained  in  the  chapter  on  The  Dietetics  of  Alcoholic 
Beverages  (also  in  the  "Dietetic  and  Hygienic  Gazette,"  May,  1896, 
p.  289;  and  R.  H.  Chittenden,  "Amer.  Jour.  Med.  Sciences,"  Jan.  to 
April,  1896,  "Influences  of  Alcohol  on  the  Chemical  Processes  of 
Digestion"). 

Constipation  in  chronic  gastritis  should  always  be  treated  dietetic- 
ally,  never  by  medicines  per  os.  A  glass  of  cold  water,  or,  preferably, 
of  Bedford  Magnesia  Spring  water,  before  breakfast,  is  a  simple  thing, 
and  yet,  if  persisted  in,  very  often  gives  an  evacuation.  The  break- 
fast should  contain  honey,  milk-sugar  or  levulose,  some  plum,  fig, 
or  prune  preserves,  and  Graham  bread.  Twice  daily  a  glass  of 
buttermilk  or  kefyr  may  be  administered,  if  agreeable  to  the  patient. 
When  the  constipation  resists  this  diet  at  the  beginning,  a  trial  for 
the  first  week  should  be  made  with  large  colon  irrigations,  with  one 
liter  of  normal  salt  solution  introduced  in  the  knee-elbow  position. 

*J.  Talugyay  &  Sons,  Pressburg. 

fThe  "  rationale  "  of  the  administration  of  alcohol  is  governed  by  its  effects  on  the 
gastric  digestion  as  observed  in  test-meal  analysis — if  it  impedes  digestion  it  must  be 
forbidden. 


470  CHRONIC    GASTRITIS. 

Fleiner's  enemata  of  250  c.c.  (^  pint)  of  pure  olive  oil  are  more 
lasting  in  their  effects,  one  enema  sometimes  keeping  the  bowels 
regular  for  a  week.  When  diarrhea  is  present,  large  irrigations  of 
warm  water,  by  removing  fermenting  and  putrefactive  colon  con- 
tents, frequently  cure  it  without  other  medication.  But  strict  diet- 
ing for  a  few  days  is  always  advisable  in  exhaustive  diarrheas,  as  it 
shortens  the  attack.  In  diarrheas,  as  well  as  in  constipation,  the 
state  of  the  gastric  secretion  must  be  regarded,  and  HCl  or  alkalies 
must  be  supplied,  as  the  case  may  be.  Excess  of  HCl  secretion  may 
provoke  diarrhea  by  causing  carbohydrate  indigestion.  A  diet  of 
Pasteurized  milk  and  some  stimulant,  as  brandy,  and,  perhaps, 
albumin  water  for  forty-eight  hours,  to  the  exclusion  of  everything 
else,  is  most  effective.  Soup  made  of  bouillon  and  thickened  with 
wheat-flour  toasted  brown  in  hot  butter,  is  quite  binding.  ' '  Eichel- 
cacao,"  a  palatable  German  preparation  of  chocolate,  can  be  recom- 
mended for  its  constipating  effect,  as  it  contains  much  tannin. 

For  special  full  diet-lists  and  further  dietetic  directions  concerning 
this  disease,  as  well  as  other  recipes,  we  refer  to  the  section  especially 
devoted  to  this  subject — the  chapter  on  Dietetics  (pp.  225-228). 

As  Oilman  Thompson  points  out,  there  are  some  persons  in  whom 
the  digestion  of  salt  and  smoked  meats  seems  to  be  more  easily 
accomplished  than  that  of  prepared  fresh  meat.  Niemeyer  offers 
the  explanation  that  these  preparations  are  less  likely  to  decompose 
in  the  stomach.  As  a  rule,  there  is  very  little  fermentation  and 
formation  of  organic  acids  in  chronic  gastritis.  After  carefully 
observing  this  point,  we  maintain  that  it  is  not  necessar)^  to  with- 
hold the  saccharine  and  farinaceous  foods,  as  Oilman  Thompson 
suggests  (loc.  cit.,  p.  508).  On  the  contrary,  they  should  be  liberally 
supplied,  as  amylolysis  progresses  rapidly  in  stomachs  that  secrete 
no  HCl,  and  test-meals  in  my  experience  do  not,  as  a  rule,  show 
the  excess  of  organic  acids  asserted  by  von  Leube,  Ewald,  and 
Rosenheim. 

Balneological. — There  is  much  truth  in  what  Prof.  Ira  Remsen 
said  when  he  opined  that  the  effect  of  the  use  of  natural  or  mineral 
spring  waters  was  not  attributable  to  the  chemical  constituents  or 
salts  of  these  waters,  but  more  to  the  favorable  mode  of  life,  the 
better  diet,  the  greater  introduction  of  plain  water  into  organisms 
which  previously  received  very  little  of  it,  and,  lastly,  to  important 
psychic  influences.  To  these  may  be  added  the  perfect  rest,  com- 
fort, and  auxiliary  methods  of  treatment  employed  at  the  springs. 


MINERAL    WATERS,    BATHS,    GYMNASTICS.  47 1 

Thousands  of  Americans  visit  the  German,  Austrian,  and  French 
spas  annually,  when  they  might  have  almost  the  same  waters — 
and  sometimes  much  better  ones — in  their  own  country.*  Obser- 
vations are  very  numerous  on  the  treatment  of  chronic  gastritis  by 
mineral  waters,  but  are  rather  inexact  and  based  upon  imperfect 
histories,  as  many  cases  are  called  chronic  gastritis  which,  in  fact, 
do  not  deserve  the  name.  One  can  not  well  judge  of  the  effect  of 
the  waters  alone,  as  they  are  always  combined  with  dieting.  The 
systematic  drinking  of  alkaline  waters  must  not  be  estimated  to  be 
worth  more  than  that  of  a  poor  substitute  for  lavage.  As  the  object 
is  to  promote  the  solution  and  evacuation  of  mucus,  all  waters  will 
be  equally  serviceable,  even  ordinary  spring  or  hydrant  water.  The 
salts  can  be  added  to  imitate  the  real  composition  of  the  famous 
springs,  and  are  made  by  several  wholesale  manufacturers  of  effer- 
vescent salts  for  this  purpose,  so  that  the  poorer  patients  may  have 
the  effect  of  mineral  springs  at  home. 

(For  the  effects  and  contraindications  of  mineral  waters  the  reader 
is  referred  to  the  section  on  Mineral  Springs.  The  composition  of 
artificial  Carlsbad  salts  is  given  on  pp.  337  and  338.) 

In  the  use  of  alkaline  chlorids  it  is  expected  to  stimulate  the 
secretion  of  HCl.  Hot  spring  waters  must  be  cooled,  and  the  cold 
water  warmed;  and  in  dilatation  and  atony,  the  patient  had  best 
abandon  the  use  of  water  in  this  manner  entirely. 

Baths. — As  in  chronic  gastritis  the  general  metabolic  processes 
are  much  depressed,  a  cold  sponge-bath  taken  before  breakfast  will 
gradually  make  the  dyspeptic  more  resistant  by  its  stimulation  of 
cellular  oxidation  and  its  hardening  effect.  Warm  baths  we  advise, 
for  purposes  of  cleanliness  only,  once  or  twice  a  week. 

Gymnastics. — All  patients  with  chronic  gastritis  should  be  en- 
couraged to  take  moderate  exercise:  walking,  bicycle  riding,  horse- 
back riding;  also  rowing  and  swimming.  A  pair  of  four-pound 
dumb-bells  for  men  and  two-pounders  for  women  should  be  used 
three  times  daily,  each  time  for  five  minutes,  with  three  minutes  of 
rest  intervening  between  the  five  minutes  of  exercise.  This  will 
make  fifteen  minutes  of  training,  and  should  be  done  before  dressing, 
in  the  undergarments,  immediately  after  the  cold  sponge-bath. 
Great  care  should  be  bestowed  upon  the  tonicity  of  the  abdominal 

*  In  extended  travels  through  our  Eastern  States,  I  have  visited  20  mineral  springs 
discharging  very  palatable — sometimes  carbonated — waters  that  are  not  at  all  known 
except  to  people  living  in  the  immediate  vicinity. 


472  CHRONIC    GASTRITIS. 

muscles.  Loss  of  the  unconsciously  and  continuously  acting  tonus 
of  these  muscles  is  a  most  potent  factor  in  the  etiology  of  dilatation, 
gastroptosis,  and  floating  kidney.  There  are,  of  course,  other  causes ; 
but  even  if  the  attachments  of  an  organ  are  loosened,  it  can  not 
wander  far  from  its  normal  location  with  a  vigorous,  unrelenting, 
external  abdominal  wall.  Therefore,  all  patients  subject  to  digestive 
diseases,  except  ulcer  and  carcinoma,  should  train  their  abdominal 
muscles  and  keep  them  active.  Sandow's  directions  for  accom- 
plishing this,  as  described  in  his  book,  are  excellent. 

Rest. — When  the  patient  has  lost  weight  and  becomes  emaciated, 
gymnastics  are  out  of  place ;  then  an  absolute  rest  cure  is  peremptory. 

Electricity. — The  faradic  and  galvanic  currents  are  useful  in  the 
treatment  of  chronic  gastritis.  The  former  may  be  used  as  general 
external  faradism,  which  is  one  variety  of  a  general  massage.  One 
pole,  in  shape  of  a  broad,  flat  electrode,  is  moved  slowly  up  and 
down  over  the  spinal  column,  while  the  other  is  moved  over  both 
arms  and  limbs,  and  particularly  over  the  abdominal  muscles.  With 
one  pole  over  the  spine,  and  the  other  over  the  epigastrium,  the 
current  appears  to  go  directly  through  the  stomach,  and  yet  there 
is  no  evidence  that  the  organ  does  contract.  In  this  case  it  is  doubt- 
ful whether  any  current  reaches  the  stomach  at  all.  There  is  as  yet 
no  satisfactory  explanation  of  how  the  good  effects  observed  after 
this  method  are  brought  about.  However,  they  may,  perhaps,  be 
largely  attributable  to  the  abdominal  massage  and  the  psychic  in- 
fluence. For  the  intragastric  application  of  both  the  faradic  and 
galvanic  currents,  the  practical  intragastric  electrode  of  Einhorn  is 
possibly  the  most  convenient.  The  secretion  of  gastric  juice  can  not 
be  influenced  by  either  the  faradic  or  galvanic  current,  nor  can  the 
motility  be  enhanced  (J.  C.  Hemmeter,  "New  York  Med.  Journal," 
June  22,  1895,  p.  769).  As  the  currents  usually  employed  for  this 
purpose  are  too  weak  to  effect  a  contraction  of  the  muscularis, 
Meltzer  ("New  York  Med.  Journal,"  June  15,  1895)  holds  that  per- 
cutaneous and  direct  faradization  of  the  stomach  and  intestines  can 
not  produce  any  contraction  of  these  parts.  Max  Einhorn  ("Archiv 
f.  Verdauungskrankheiten, "  Bd.  11,  S.  454),  in  his  recent  contribu- 
tions to  the  subject,  is  of  entirely  opposite  opinion  (see  part  i,  p.  60). 
As  Ziemssen  (" Electrizitat  i.  d.  Medizin,"  1887,  p.  445)  has  em- 
phasized, it  is  not  necessary  to  effect  gastric  contraction  in  order 
that  electricity  should  prove  beneficial.  In  fact,  it  would  appear 
that  a  neurometabolic  or  neurotrophic  effect  of  electricity  is  becoming 


MEDICINAL    TREATMENT.  473 

more  and  more  understood,  so  that  the  faradic  and  galvanic  current 
should  be  employed,  both  externally  over  the  spine  and  epigastrium, 
and  internally  with  the  intragastric  electrode;  not  because  of  any 
undeniable  evidence  that  it  can  influence  secretion,  motility,  or 
absorption,  but  because  of  the  general  uniformity  of  opinion  among 
experienced  clinicians  that  chronic  gastritis  is  undoubtedly  benefited 
by  electrical  treatment.  Even  Goldschmidt  (loc.  cit.),  whose  results 
regarding  the  effect  of  the  faradic  and  galvanic  currents  on  secretion 
and  motilitv  are  entirelv  negative,   admits  that  these  are  useful 


Fig.  34.— Connective-tissue  Hyperplasia  Separating  Remnants  of  Glands  which  Show 
A  Small  Nucleus  Surrounded  by  a  Thin  Shell  of  Protoplasm.— (/Vom  the  Author's 
Clinic,  University  0/ Maryland.)     X  70  diameters. 

agents  in  the  treatment,  even  benefiting  stomach  diseases  depending 
upon  organic  changes.  It  is  evident  that  while  experimental  evi- 
dence of  the  manner  in  which  electricity  acts  on  the  stomach  is  neces- 
sary, the  clinical  approval  of  its  therapeutic  utility  is  more  important. 
Medicinal  Treatment. — Two  chemicals  seem  to  have  maintained 
their  reputation  as  being  able  to  benefit  the  disease ;  these  are  argentic 
nitrate,  either  in  form  of  gastric  spray  (i  :  1000)  or  lavage  (i  :  2000), 
or  in  form  of  solution,  0.3  to  120  of  peppermint  water;  of  this,  one 
tablespoonful  three  times  daily,  on  an  empty  stomach.  The  second 
drug  is  bismuth  subnitrate,  recommended  by  Penzoldt  (loc.  cit.), 


474  CHRONIC    GASTRITIS. 

Fleiner  (loc.  cit.),  and  Pick  {loc.  cit.)  in  large  doses,  4  to  6  gm.,  in 
wafers.  With  both  remedies  we  have  had  experience,  and  prefer 
the  latter,  together  with  bismuth  subgallate,  because  it  certainly 
diminishes  the  amount  of  mucus  formed  in  alcoholic  gastritis: 

B .      Bismuth  subnitratis, 48  gm.  .^^ij 

Bismuth  subgallatis, 16  gm.  .^iv-        M. 

Fiant  pulv.  No.  xxiv. 
SiG. — One  powder  in  a  wafer  four  times  daily. 

Unfortunately,  this  treatment  is  constipating,  and  must,  there- 
fore, be  combined  with  a  diet  promoting  evacuation  and  the  use  of 


Z^'^^--. 


^'"■i^-^ 


-^-^-— ^^^^"-/fi^ 


Fig.  35.— Detachment  of  Remnants  of  Secretory  Cells  Containing  Vacuoles  from 
Lumen  of  Peptic  Duct. — {Prom  the  Author'' s  Clinic,  University  of  Maryland.")  X  325 
diameters. 

Saratoga  Congress  water.  Argentic  nitrate  is  best  employed  in  form 
of  the  intragastric  spray  or  in  the  lavage.  These  drugs  are  per- 
missible, particularly  when  diet  and  massage  can  not  be  properly 
carried  out.  They  were  originally  suggested  for  the  treatment  of 
ulcer;  their  efficacy  in  some  cases  of  chronic  gastritis  is,  however, 
undoubted.  The  bismuth  subnitrate  and  subgallate  ma)^  be  applied 
by  means  of  an  intragastric  powder-blower.  By  the  use  of  the 
fluoroscope  and  X-rays  it  is  demonstrable  that  the  entire  stomach 
can  be  coated  in  this  way. 

The  Hygiene  of  the  Mouth. — The  frequent  association  of  stomatitis, 


TREATMENT  OF  SPECIAL  SYMPTOMS.  475 

gingivitis,  and  glossitis  with  this  disease  makes  it  all-important  that 
the  mouth  should  be  in  a  healthy  condition.  Dental  defects  and 
their  repairs  have  already  been  referred  to;  but,  in  addition,  the 
mouth  should  be  disinfected  after  each  meal.  After  removing  the 
food  debris  by  toothpick  and  brush,  one  of  the  following  antiseptic 
lotions  should  be  used,  both  on  the  brush,  applied  to  the  teeth  and 
the  root  of  tongue,  and  as  a  mouth-wash : 

R.     Acid,  thymol, 0.25  gr.  iv 

Acid,  benzoic, ,      3.0  gr.  xlv 

Tinct.   eucalypt., 15.0  f^iiiss 

Alcohol, loo.o  f^iiiss 

01.  menth.  pip., 0.75  Tr\,xij.      M. 

SiG. — Pour  sufficient  into  ^  of  a  glass  of  water  until  turbidity  results. 

If  much  decomposition  be  present,  0.8  hydrarg.  bichlorid.  corrosiv.  maybe  added. 

R.      Spirit,  lavandul., 

Spirit,  myrcice, aa  50.0  f^xiiss 

Tinct.  myrrh., 5.0  f^j 

Saccharin, i.o  gr.  xv 

Menthol, i.o  gr.  xv.           M. 

SiG. — One-half  to  one  teaspoonful  to  a  glass  of  water. 

Treatment  of  the  Symptoms. — This  is  of  subsidiary  importance  to 
systematic  treatment  by  diet,  hygiene,  and  lavage ;  but  in  cases  that 
have  progressed  too  far,  or  in  secondary  forms  that  are  incurable 
(albuminuria,  diabetes,  etc.),  a  special  therapy  for  symptoms  may 
be  indispensable. 

The  treatment  of  loss  of  appetite  which  we  advocate  is  the  following : 

Lavage  with  chlorid  of  sodium,  oss  to  the  quart  or  a  decinormal 

solution  of  HCl ;  fluid  extract  of  condurango  in  doses  of  5 j ;  tincture 

or  elixir  of  gentian.     Lavage  with  quassia,   Colombo,   or  calisaya 

solutions  will  often  produce  appetite.     Orexin,  a  stimulant  to  the 

appetite  and  HCl  secretion  (first  recommended  by  Penzoldt),  is  best 

given  in  the  following  form : 

R.     Orexin,  basic, 0.2      gr.  iiiss. 

SiG. — Make  one  wafer.   Take  one  wafer  in  a  cup  of  bouillon  half  an  hour  before 
meals,  t.  i.  d. 

Our  favorite  tonic  for  anorexia  in  chronic  gastritis  contains  strych- 
nin and  hydrochloric  acid  in  the  following  proportion  for  adults: 

R .     Strych.  sulphatis, 0.02  gr.  j/ 

Acid,  hydrochlorici  dilut.,      19.4  f  3  v 

Elixir  gentianse, q.  s.  180.0  f^vj.       M. 

SiG. — f§ss  in  ^ij  aquae  after  meals,  through  a  glass  tube. 
Fluid  extract  condurango  f^xij  may,  if  desired,  be  added. 

Some  old  gastritics  can  not  tolerate  so  much  hydrochloric  acid.     Then  the  dose  must 

be  reduced  to  five  drops,  t.  i.  d.  Always  precede  the  administration  of  HCl  by  a  test- 
meal  analysis,  so  as  to  find  out  the  degree  of  HCl  deficiency. 


476  CHRONIC    GASTRITIS. 

Pyrosis  and  eructation  are  best  treated  with  magnesia  and  sodium 
bicarbonate,  according  to  the  principles  laid  down  in  the  management 
of  hyperacidity. 

Pain. — If  diet  and  lavage  do  not  relieve  this,  it  is  best  to  subject 
the  patient  to  a  rest  cure  of  eight  days,  with  hot  external  fomenta- 
tions to  epigastrium.  The  galvanic  current  has  been  a  very  reliable 
means  of  easing  pain  in  this  affection.  Opiates  and  other  narcotics 
must  be  avoided ;  but,  in  the  very  rare  cases  where  this  is  impossible, 
they  should  be  given  by  the  rectum  or  (morphin)  hypodermically. 

The  same  treatment  applies  also  to  vomiting,  which  is,  as  a  rule, 
relieved  by  diet,  lavage,  small  pieces  of  ice,  or  champagne;  very 
rarely  does  it  become  so  distressing  a  symptom  as  to  require  a  hypo- 
dermic injection  of  morphin.  Spraying  the  stomach  with  menthol 
and  cocain  in  weak  solutions  relieves  vomiting  when  lavage  has 
failed. 

Deficiency  of  gastric  juice  and  ferments  may  be  supplanted  by 
the  use  of  HCl  internally,  as  per  formula  stated  above.  If  HCl  is 
no  longer  tolerated,  it  is  well  to  convert  the  entire  gastric  chemistry 
into  an  alkaline  proteolysis  by  pancreatin  and  bicarbonate  of  sodium. 
In  long-standing  cases  the  mucosa  acquires  a  strange  hypersensitive- 
ness  to  all  acids,  which  points  the  way  to  this  plan  of  treatment. 
Reliable  pancreatin  and  sodium  bicarbonate,  of  each  five  grs.,  are 
recommended  by  Boas,  Witte,  Simon,  Schering,  and  Penzoldt.  In 
our  private  sanitarium  we  have,  by  a  study  of  test-meals,  found 
Reichmann's  preparation  of  fresh  ox  pancreas  an  effective  digestant. 
It  is  made  by  finely  mincing  one  ox  pancreas  and  extracting  it  with 
15  per  cent,  alochol  or  brandy  for  forty-eight  hours,  and  straining. 
The  dose  is  a  wineglassful  after  meals.  We  very  rarely  found  it 
necessary  to  give  pepsin;  for  if  HCl  is  still  secreted,  pepsin  will  be 
found  also,  and  if  HCl  be  absent,  although  the  ferments  may  be 
wanting,  it  is  expedient  to  give  only  the  acid,  as  proteolysis  is  suffi- 
ciently effective  in  the  intestine,  and  the  effect  of  the  HCl  is  to  im- 
prove the  appetite  and  prevent  intestinal  fermentations. 

Motor  insufficiency  is,  fortunately,  a  very  rare  occurrence  in  the 
disease,  but,  if  present,  may  be  met  with  use  of  lavage,  electricity, 
hydrotherapy,  massage,  and  strychnin.  This  will  be  more  fully 
treated  in  the  section  on  this  defect. 

Psychic  depression  may,  according  to  the  most  prominent  under- 
lying cause,  require  one  or  several  of  the  methods  of  treatment  men- 
tioned.    But  regular  bowel  movements,  electricity,  a  daily  tepid  or 


ADVANCED    CHEMICAL    AND    MECHANICAL   DEFECTS.  477 

cold  sponge-bath,  moderate  exercise,  massage,  surf  baths,  and 
climatic  changes  are  the  most  reliable  means  to  be  employed.  Some 
of  these  cases  will  not  recover  until  brought  to  a  properly  managed 
sanitarium  for  digestive  sufferers. 

Advanced  Chemical  and  Mechanical  Defects. — When  the  glandular 
elements  have  been  completely  destroyed  as  a  result  of  hypertrophic 
or  atrophic  metamorphosis  of  the  mucosa  and  degenerative  processes 
in  the  muscularis,  and  also  of  cirrhotic  contraction  of  the  stomach, 
secretion,  absorption,  and  motility  no  longer  exist.  The  gravest 
defect  is  the  loss  of  motility.  For,  in  the  total  absence  of  all  gastric 
digestion,  no  food  except  a  small  fraction  of  the  carbohydrates 
(ptyalin)  enters  into  solution.  The  ingesta  are  not  reduced  suffi- 
ciently in  size,  because  there  is  no  churning  peristalsis  and  no  secre- 
tion; they  are  not  evacuated  into  the  duodenum,  because  the  pro- 
pelling peristalsis  is  missing.  Now,  although  there  is  no  stenosis  of 
the  pylorus  from  cicatricial  contraction  or  neoplasm,  we  have  seen 
such  cases  in  which  there  was  not  even  a  pyloric  hyperplasia.  Under 
these  conditions  there  is  what  we  may  term  a  "relative  pyloric 
stenosis";  that  is,  the  pylorus  is  relatively  too  small  and  peristalsis 
too  defective  for  the  passage  of  the  insufficiently  macerated  ingesta. 
This  combination  of  things  may  occur  in  the  last  stages  of  chronic 
gastritis  accompanied  by  the  clinical  aspects  of  progressive  anemia, 
due  to  inevitable  malnutrition,  and  may  simulate  carcinoma.  Opera- 
tions have  been  undertaken,  in  the  author's  experience,  where  the 
markedly  thickened,  hyperplastic  muscularis  gave  the  impression  of 
a  gastric  neoplasm,  and  the  exploratory  incision  revealed  the  effects 
of  a  chronic  hyperplastic  gastritis. 

The  intestine,  although  it  may  be  healthy,  can  not  supplant  the 
absent  digestion  of  the  stomach  by  its  vicarious  action,  since  it  gets 
no  chance  to  do  so,  the  gastric  contents  fermenting,  and  eventually 
being  expelled  by  emesis,  rather  than  propelled  into  the  duodenum. 
This  state  should  be  treated  exactly  as  if  there  were  a  real  pyloric 
stenosis,  namely,  by  operation, — either  by  gastro-enterostomy  or  by 
dilatation  of  the  pylorus ;  or,  if  an  excessive  atonic  gastrectasia  with 
immense  enlargement  of  the  stomach  and  normal  pylorus  be  present, 
by  gastroplication  (Bircher).  So  far  it  appears  that  gastro-enter- 
ostomy has  been  done  but  once  under  these  conditions  for  typical 
gastric  atrophy  (Westphalen,  "  Petersburger  med.  Wochenschr.," 
1890,  37,  38)  occurring  in  a  tuberculous  patient.  As  the  expelling 
force  of  the  peristalsis  is  much  reduced,   gastro-enterostomy  will 


478 


CHRONIC    GASTRITIS. 


probably  be  preferable  to  dilatation  of  the  pylorus.  The  indications 
for  surgical  operations  upon  the  stomach  have  been  separately  con- 
sidered (p.  349). 


LITERATURE 


ON   ACUTE   AND    CHROXIC    GASTRITIS. 


In  addition  to  the  text-books  of — 


Debove  and  Remond, 

Einhorn, 

Kleiner, 

Martin,  Sidney, 

Bamberger, 

Birch-Hirschfeld, 

Boas, 

Bouveret, 

Brinton, 

Cohnheim, 

Cruveilhier, 

Dujardin-Beaumetz, 


Eichhorst, 

Ewald, 

Fleischer, 

Forster, 

Henoch, 

Jiirgensen, 

Kunze, 

Lebert, 

Leo, 

Leube, 

Liebermeister, 

Hay  em. 


Niemeyer, 

Orth, 

Oser, 

Penzoldt, 

Pick, 

Riegel, 

Rokitansky, 

Rosenheim, 

Striimpell, 

Trousseau, 

Wegele, 

Ziegler,  and  others. 


1.  Aaron,  C.  D.,  "Chronic  Dyspepsia,"  "Trans.  Mich.  Med.  Soc,"  Grand 
Rapids,  1898,  281-291. 

2.  Beaumont,  "  Experiments  and  Observations  of  the  Gastric  Juice  and  the 
Physiology  of  Digestion,"  Combe's  edition,  1833. 

3.  Benedict,  A.  L.,  "  Some  Thoughts  on  Subacute  and  Chronic  Gastritis," 
"Medicine,"  Detroit,  1897,  iii,  353-359. 

4.  Boas,  J.,  "  Ueber  Schwefelwasserstoff  bildung  bei  Magenkrankheiten," 
"  Centralblatt  f.  klin.  Med.,"  1895. 

5.  Cahn,  A.,  "  Die  Verwendung  der  Peptone  als  Nahrungsmittel,"  "  Berlin. 
kUn.  Wochenschr.,"  1893. 

6.  Cagigal,  A.  O.,  "  Um  caso  de  gastrite  chronica  e  arterio  esclerose  com- 
modificacoes  nervosas  perephericas,"  "  Coimbra  med.,"  1898,  xviii,  87,  88, 

7.  Chaffee,  F.  F.,  "  Chronic  Gastritis,"  "  Trans.  Vermont  Med.  Soc,"  1895- 
'96;  Burlington,  1897,47-65. 

8.  Charles,  "  On  a  Case  of  Cirrhosis,  or  Fibroid  Infiltration  of  the  Stomach," 
"  Dublin  Jour,  of  Med.  Science,"  1878. 

9.  Curschmann,  "Sitzung  des  Aerztlichen  Vereins  zu  Hamburg  vom  19. 
Mai,  1885,"  "  Deutsche  med.  Wochenschr.,"  1885. 

10.  Cutler,  E.  G.,  "General  Remarks  on  Gastric  Dyspepsia,"  "  Boston  Med. 
and  Surg.  Jour.,"  1897,  cxxxvii. 

11.  Deekens,  A.  H.,  "Chronic  Catarrhal  Gastritis:  Its  Pathology,  Sympto- 
matology, and  Treatment,"  "  Med.  Sentinel,"  Portland,  Oregon,  1898,  VI,  123- 

134- 

12.  Deininger,  "  Zvvei  Falle  von  Idiopathischer  Gastritis  Phlegmonosa," 
"  Deutsches  Archiv  fiir  khn.  Med.,"  xxiii. 

13.  Ebstein,  "  Ueber  die  Verjinderungen  welche  die  Magenschleimhaut 
durch  Einverleibung  von  Alcohol  und  Phosphor  erleidet,"  "  Virchow's  Arch.," 
Bd.  LV. 


LITERATURE    ON    ACUTE    AND    CHRONIC    GASTRITIS.  479 

14.  Edinger,  "  Zur  Kenntniss  der  Driisenzellen  des  Magens,  besonders 
beim  Menschen,"  "  M.  Schultzer's  Archiv,"  Bd.  xvii,  S.  209. 

15.  Eisenlohr,  "  Ueber  primare  Atrophic  der  Magen-  und  Darmschleimhaut 
und  deren  Beziehung  zu  schwerer  Anamie  und  Riickenmarkserkrankungen," 
"  Deutsche  med.  Wochenschr.,"  1892. 

16.  Ewald,  "  Zur  Diagnose  und  Therapie  der  Magenkrankheiten,"  "  Berlin, 
klin.  Wochenschr.,"  1886. 

17.  Fenwick,- Lecture  on  "Atrophy  of  the  Stomach,"  "  Lancet,"  1877. 

18.  Fenwick,  "On  Atrophy  of  the  Stomach,"  London,  1880. 

19.  Fenwick,  "  Ueber  den  Zusammenhang  einiger  krankhafter  Zustande  des 
Magens  mit  anderen  Organerkrankungen,"  "  Virchow's  Archiv,"  Bd.  cviil. 

20.  Fleiner,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
"  Volkmann's  Sammlung  klinischer  Vortrage,"  Nr.  103,  1894. 

21.  Fleiner,  "  Ueber  die  Behandlung  der  Constipation,  etc.,  mit  grossen 
Oelklystieren,"  "Berlin,  klin.  Wochenschr.,"  1893,  Nr.  3  und  4. 

22.  Gerhardt,  "  Magenkatarrh  durch  lebende  Dipterenlarven,"  "  Jenaer 
med.  Zeitschr.,"  iii. 

23.  Glax,  "  Die  Magenentziindung,"  "Deutsche  med.  Zeitung,"  1894. 

24.  Gluzinski,  "Ueber  das  Verhalten  des  Magensaftes  in  fieberhaften 
Krankheiten,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xlii. 

25.  Gostkowski,  "  Ein  Fall  von  NH3  Vergiftung  mit  totaler  Abstossung  der 
Magenschleimhaut,"  Dissert.,  Leipzig,  i895-'96. 

26.  Griitzner,  P.,  "  Neue  Untersuchungen  iiber  Bildung  und  Ausscheidung 
des  Pepsins  im  Magen,"  Breslau,  1875. 

27.  Hanot  et  Gombault,  "  Etude  sur  la  Gastrite  chronique  avec  sclerose  sous- 
muqueuse  hypertrophique  et  retroperitonite  calleuse,"  "Archiv  de  Physiolo- 
gie,"  1882,  IX. 

28.  Harnack,  E.,  "  Ueber  die  Verschiedenheit  gewisser  Aetzwirkungen  auf 
lebendes  und  todtes  Magengewebe,"  "  Berlin,  klin.  Wochenschr.,"  1892. 

29.  Hayem,  "  Sur  I'anatomie  pathologique  de  la  gastrite  parenchymateuse 
hyperpeptique,"  Paris,  1893. 

30.  Hayem,  "  Classement  des  varietes  anatomiques  des  gastrites,"  "  Soc. 
Med.  des  hop.  de  Paris,"  24,  vii,  1896. 

31.  Hayem,  "  Gastrite  degenerative,"  "  Soc.  Med.  des  hop.  de  Paris,"  28,  x, 
1896. 

32.  Hayem,  G.,  et  G.  Lion,  "  Traitement  des  gastrites"  (Abstr.),  "  Rev.  de 
therap.  med.-chir.,"  Paris,  1897,  LXiv,  429-433. 

33.  Henne,  "  Experimentelle  Beitrage  zur  Therapie  der  Magenkrankheiten," 
"  Deutsche  Zeitschr.  f.  klin.  Med.,"  xix,  Supplement. 

34.  Honigmann,  "  Epikritische  Bemerkungen  zur  Deutung  des  Salzsaure- 
befundes  im  Mageninhalt,"  "Berlin,  klin.  Wochenschr.,"  1893. 

35.  Honigmann,  "Ueber  einige  wesentliche  Punkte  aus  der  Diatetik  fiir 
Magenkranke,"  Sep.-Abdr.  aus  der  "  Zeitschrift  fiir  Krankenpflege,"  1894. 

36.  Immermann,  "Ueber  die  Functionen  des  Magens  bei  Phthisis  tuber- 
culosa," "  Verhandlungen  des  Congresses  fur  innere  Medicin,"  Wiesbaden, 
1889. 

37.  Jaworski,  "  Zur  Diagnose  des  atrophischen  Magenkatarrhs,"  "  Verhand- 
lungen des  Congresses  fiir  innere  Medicin,"  Wiesbaden,  1888. 

38.  v.  Kahlden,  "Ueber  chronisch-sclerosirende  Gastritis,"  "  Centralblatt 
f.  klin.  Med.,"  1887,  Nr.  16. 


480  CHRONIC    GASTRITIS. 

39.  Kalnin,  K.  K.,  "Apropos  of  Application  of  Tincture  of  Iodine  in  the 
Treatment  of  Chronic  Gastric  Catarrh." 

40.  Kaufmann,  "  Zwei  Falle  geheilter  pernicioser  Anamie,"  etc.,  "  Berlin, 
klin.  Wochenschr.,"  1891. 

41.  King,  C,  "  Dyspepsia,"  "  N.  Y.  Lancet,"  1898,  297-300. 

42.  Klebs,  "  Handbuch  d.  patholog.  Anatomie,"  1868,  S.  174. 

43.  Kuhnau,  "Berlin,  klin.  Wochenschr.,"  1897,  Nr.  19. 

44.  Kulnefif,  "  Ueber  basische  Zersetzungsproducte  im  Magen-  und  Darm- 
inhalt,"  "Berlin,  klin.  Wochenschr.,"  1891. 

45.  Kupffer,  C,  "  Epithel  und  Driisen  des  menschl.  Magens,"  Miinchen, 
1883. 

46.  Leary,  F.,  "Diphtheric  Gastritis,"  "Jour.  Boston  Soc.  Med.  Sc," 
1897,  No.  16,  8-12. 

47.  Lesser,  "  Cirrhosis  ventriculi,"  Inaug.  Diss.,  Berlin,  1876. 

48.  Leube,  "Ueber  die  Therapie  der  Magenkrankheiten,"  "  Volkmann's 
S  immlung  klin.  Vortrage,"  1873,  N^"-  62. 

49.  Leube,  "  Beitrage  zur  Diagnostik  der  Magenerkrankungen,"  "  Deutsches 
Archiv  f.  klin.  Med.,"  1883,  xxxili. 

50.  Leube,  "  Ueber  eine  neue  Art  von  Fleischsolution  als  Nahrungs-  und 
Heilmittel   bei   Erkrankungen  des  Magens,"  "  Berlin,  klin.   Wochenschr.," 

1873- 

51.  Litten    und    Rosengart,    "  Ein    Fall   von    fast  volligem   Erloschen  der 

Secretion  des  Magensaftes  (Atrophie  der  Magenschleimhaut),"  "  Zeitschr.  f. 
klin.  Med.,"  xiv. 

52.  Losch,  "  Ueber  die  nach  Einwirkung  abnormer  Reize  auf  die  Magen- 
schleimhaut auftretenden  pathologisch-anatomischen  Veranderungen,"  "  All- 
gem.  Wien.  med.  Zeitung,"  1881,  Nr.  50. 

53.  Lyon,  G.,  "  Traitement  de  la  gastrite  hyperpeptique  "  (Abstr.),  "Rev. 
de  therap.  med.  chir.,"  Paris,  1898,  LXV,  757-766. 

54.  Marfan,  "  Troubles  et  lesions  gastriques  dans  la  phthisie  pulmonaire," 
Paris,  1889. 

55.  Manassein,  "  Chemische  Beitrage  zur  Fieberlehre,"  "  Virchow's  Archiv," 
Bd.  LV. 

56.  Mathieu,  A.,  "  Un  cas  d'uremie  gastrique  chronique,"  "  Bull.  gen.  de 
therap.,"  etc.,  Paris,  1898,  CXXXVI,  743-750. 

57.  Mester,  B.,  "  Ueber  Magensaft  und  Darmfaulniss,"  "  Zeitschr.  fiir  klin, 
Med.,"  XXIV. 

58.  Meyer,  G.,  "  Zur  Kenntniss  der  sogenannten  Magenatrophie,"  "  Zeitschr. 
f.  klin.  Med.,"  Bd.  xvi. 

59.  Mintz,  "  Ein  Fall  von  Gastritis  phlegmonosa  diffusa  im  Verlaufe  eines 
Magenkrebses,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xlix. 

60.  Murdoch,  F.  H.,  "  The  Diagnosis  and  Treatment  of  Gastric  Catarrh," 
"  N.  Y.  Med.  Jour.,"  1897,  Lxvii,  289. 

61.  v.  Noorden,  "  Ueber  die  Ausniitzung  der  Nahrung  bei  Magenkrank- 
heiten," "  Zeitschrift  f.  klin.  Med.,"  Bd.  xvii. 

62.  V.  Noorden,  "  Der  Stoffwechsel  der  Magenkranken  und  seine  Anspriiche 
an  die  Therapie,"  "  Berliner  Klinik,"  1893. 

63.  Nothnagel,  "  Cirrhotische  Verkleinerung  des  Magens  und  Schwund  der 
Labdriisen  unter  dem  klinischen  Bilde  der  perniciosen  Anamie,"  "  Deutsches 
Archiv  f.  klin.  Med.,"  XXiv. 


LITERATURE    ON   ACUTE   AND    CHRONIC    GASTRITIS.  48 1 

64.  Oppler,  B.,  "  Der  chronische  Magenkatarrh  und  seine  Behandlung," 
"  Berliner  Klinik,"  1898,  Heft  cxxiil,  1-25, 

65.  Oppoizer,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
"  Zeitschr.  d.  k.-k.  Ges.  d.  Aerzte  zu  Wien,"  Wien,  1857,  xiii. 

66.  Penzoldt,  "Beitrag  zur  Lehre  von  der  menschlichen  Magenverdauung," 
"  Deutsches  Archiv  f.  klin,  Med.,"  Bd.  li  u.  liii. 

67.  Penzoldt,  "  Salzsaures  Orexin,  ein  echtes  Stomachicum,"  "  Therapeu- 
tische  Monatshefte,"  Februar,  1890. 

68.  V.  Pfungen,  "  Ueber  Atonie  des  Magens,"  Wien,  1887. 

69.  Pick  (Coblenz),  "  Die  Behandlung  des  ehronischen  Magenkatarrhs  mit 
grossen  Bismuthdosen,"  "Berlin  klin.  Wochenschr.,"  1893. 

70.  Popofif,  P.  M.,  "  Ueber  Magenkatarrh,"  "  Zeitschr.  f.  kl.  Med.,"  Bd.  xxxii, 

XXII. 

71.  Quincke,  "  Luftschlucken,"  "  Verhandlungen  des  VIII.  Congresses  fiir 
innere  Medicin,"  Wiesbaden,  1889. 

72.  Quincke,  "Ueber  perniciose  Anamie,"  "Volkmann's  Sammlung  klin. 
Vortrage." 

73.  Reed,  B.,  "  Diet  in  the  Chronic  Catarrh  of  the  Gastro-intestinal  Tract," 
"  Jour,  of  Am.  Med.  Assn.,"  Feb.  19,  1898. 

7z|.  Reichmann,  "Ueber  die  Anwendung  der  Pankreaspraparate  beim  atro- 
phischen  Magenkatarrh,"  "  Deutsche  med.  Wochenschr.,"  1889. 

75.  Reichmann,  N.,  "Zur  Diagnose  der  Gastritis  atrophicans,"  "  Gazetta 
lekanka  (Polnisch) ;  "  Berlin,  klin.  Wochenschr.,"  1898,  xxxv,  1015. 

76.  Riegel,  "  Beitrage  zur  Pathologie  und  Diagnostik  der  Magenkrankheiten," 
"  Deutsches  Archiv  f.  klin.  Med.,"  xxxvi;  "Zeitschr.  f.  klin.  Med.,"  xi. 

77.  Riegel,  "  Ueber  Diagnostik  und  Therapie  der  Magenkrankheiten," 
"  Volkmann's  Sammlung   klin.  Vortrage,"  1886,  Nr.  289. 

78.  Rodrigues,  d'Oliveira  J.,  "  Nota  sobre  um  caso  de  gastrite  chronica 
glandular  hyperpeptica,"  "  Coimbra  med.,"  1897,  xvii,  458,  474,  494. 

79.  Rosenheim,  "  Ueber  atrophische  Processe  an  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  und  als  selbststandige  Erkrankung,"  "  Berlin. 
kUn.  Wochenschr.,"  1888. 

80.  Rosenheim,  "  Ueber  die  Magendusche,"  "  Therapeut.  Monatshefte," 
1892. 

81.  Sachs,  "  Die  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zu- 
standen,"  "Archiv  fiir  exp.  Patholog.  u.  Pharm.,"  xxii  u.  xxiv. 

82.  Schwalbe,  "  Die  Gastritis  der  Phthisiker  vom.  patholog.-anatomischen 
Standpunkte,"  "  Virchow's  Archiv,"  Bd.  cxvii. 

83.  Senator,  "  Ueber  einen  Fall  von  Hydrothionanamie  und  iiber  Selbst- 
infection  durch  abnorme  Verdauungsvorgiinge,"  "  Berlin,  klin.  Wochenschr.," 
1868. 

84.  Stintzing,  "  Zur  Structur  der  erkrankten  Magenschleimhaut,"  "  Miinch- 
ener  med.  Wochenschr.,"  1889,  Nr.  48. 

85.  Stintzing,  "  Miinchener  med.  Wochenschr.,"  1890. 

86.  Symes,  L.,  "  Dyspeptic  Conditions,"  "  Dublin  Jour.  Med.  Sc,"  1897,  Civ, 
115-121. 

87.  Tawitzki,  "  Ueber  den  Einfluss  der  Bitterstoffe  auf  die  Mengen  der  Salz- 
saure  im  Magensaft  bei  gewissen  Formen  von  Magen-  und  Darmkatarrhen," 
"Deutsches  Archiv  f.  klin.  Med.,"  Bd.  XLViii. 

88.  Tournier,  C,  "  D'un  type  de  catarrhe  gastrique  avec  hypei^esthesie  de  la 


482  CHRONIC    GASTRITIS. 

muqueuse  et  colite  muco-membraneuse  ;  difficultes  diagnostiques  avec  I'ulcere," 
"  Prov.  medicale,"  21,  22,  1897. 

89.  Uffelmann,  "  Beobachtungen  und  Untersuchungen  an  einem  gastroto- 
mirten  fiebernden  Knaben,"  "  Deutsches  Archiv  f.  klin.  Med.,"  xx,  1877. 

90.  Virchow,  R.,  "  Der  Zustand  des  Magens  bei  Phosphorvergiftung,"  "  Vir- 
chow's  Archiv,"  Bd.  xxxi,  S.  388. 

91.  Wasbutzki,  "  Ueber  den  Einfluss  von  Magengahrungen  auf  die  Faulniss- 
vorgange  im  Darmkanal,"  "Archiv  f.  exp.  Patholog.,"  etc.,  Bd.  xxvi. 

92.  Werther,  "  Ueber  den  therapeutischen  Werth  der  Pepsinweine,"  "  Berlin, 
klin.  Wochenschr.,"  1892. 

93.  Widal,  "  Le  Bulletin  IMedicale,"  1896,  Nos.  59,  61,  64,  78,  83,  and  1897, 
No.  4. 

94.  Will,  F.  J.,  "  Gastric  Catarrh,"  "Trans.  Iowa  Med.  Soc,"  Cedar  Rapids, 
1897,  XV,  299-305. 

95.  Wolf-Gothenberg,  "  Beitrage  zur  Kenntniss  der  Einwirkung  verschie- 
dener  Genuss-  und  Arzneimittel  auf  den  menschlichen  Magensaft,"  "  Zeitschr. 
f.  klin.  Med.,"  Bd.  xvi. 

BIBLIOGRAPHY  OF  PHLEGMONOUS  GASTRITIS. 
A. 

1.  Ackermann,  "  Ein  Fall  von  phlegmonoser  Gastritis  mit  Thrombose  zahl- 
reicher  Magenvenen  und  embolischen  Heerden  in  der  Leber  und  in  den 
Lungen,"  "  Virchow's  Archiv,"  1869,  Bd.  XLV,  S.  39. 

2.  Albers,  "  Rheinisch-Westph.  med.  Correspondenzblatt,"  1884,  Nr.  5,  re- 
ported by  "Tillmann's  Archiv  f.  kUn.  Chir.,"  Berlin,   1882,  Bd.  XXVII,  S.  155. 

3.  Andral,  G.,  "  Maladies  de  I'abdomen,"  "  Clinique  medicale,"  1839, 
tome  II. 

4.  Asverus,  "  Ein  Fall  von  Gastritis  phlegmonosa,"  "  Jenaische  Zeitschr.  f. 
med.  Natur.,"  Jena,  1866,  Bd.  11,  S.  476-482. 

5.  Auvray,  "  Etude  sur  la  Gastrite  phlegmoneuse,"  "  These  de  Paris,"  1866. 

B. 

6.  Baerecke,  V.  Z.,  "Was  it  a  Case  of  Phlegmonous  Gastritis?"  "  N.  Y. 
Med.  Record,"  1898,  Liv. 

7.  Bamberger,  "  Henoch's  Klinik  der  Unterleibskrankheiten,"  Berhn,  1855, 
Bd.  II,  S.  196. 

8.  Beckler,  "  Ein  Fall  von  idiopathischer  phlegmonoser  Gastritis,"  "  Bayer, 
Aerztl.  Int.  Int.-BL,"   Miinchen,  1880,  Bd.  xxvii,  Nr.  37,  S.  403. 

9.  BelfrageandBedenius,  "  Schmidt's  Jahrb.,"  Leipzig,  1872,  Bd.  cliv,  S.  298. 

10.  Bianchette,  "  Sopra  un  laso  bi  Gastrite  Flemonosa,"  "  Gaz.  Med.  Ital.," 
Prove.  Venete.  Padova,  1875,  vol.  xvii,  p.  217. 

11.  Bonetes,  "  Sepulchretum  sive  Anatomia  Practica,"  Lib.  iii, Geneva,  1700. 

12.  Bouveret,  "  Traite  de  pathologia  Generale,"  1895,  tome  i,  p.  781. 

13.  Bret  and  Paviot,  "  Rev.  de  Med.,"  Paris,  May  10,  1894,  p.  384. 

14.  Brinton,  "  Diseases  of  the  Stomach." 

15.  Budd,  "  Organic  and  Functional  Diseases  of  the  Stomach,"  1855. 

C. 

16.  Cahn,  "Gastritis  diphtheritica  mit  acuter  gelber  Leberatrophie," 
"  Deutsches  Archiv  f.  klin.  Med.,"  Leipzig,  1883,  Bd.  xxxiv,  S.  113-121. 


LITERATURE   ON   PHLEGMONOUS   GASTRITIS.  483 

17.  Callow,  vide  Auvray  {Joe.  cit.). 

18.  Caudmont,  "Bull.  Soc.  Anat.  de  Paris,"  1848,  tome  xxxiii,  p.  273. 

19.  Chvostek,  "  Zwei  Falle  von  primarer  diffuser  phlegmonoser  Gastritis," 
"  Wien.  med.  Presse,"  1877,  Nr.  22,  29,  Bd.  xvii,  S.  693. 

20.  Chvostek,  "  Ein  weiterer  Beitrag  zur  primaren  diffusen  phlegmonosen 
Gastritis,"  "Wien.  med.  BL,"  1881,  Nr.  28,  Bd.  iv,  S.  831,  861,  891,  924,  962. 

21.  Cornil,  vide  Auvray  {loc.  cii.,  p.  20). 

22.  Cruveilhier,  vide  Raynaud,  p.  526. 

D. 

23.  Deininger,  "  Zwei  Falle  von  idiopathischer  Gastritis  phlegmonosa," 
"  Deutsches  Archiv  f.  klin.  Med.,"  Leipzig,  1878-79,  Bd.  xxii,  S.  624-632. 

24.  Dirner,  "Gastritis  phlegmonosa,"  "  Orbosi  hetila,"  Budapest,  1881,  vol. 
XXV,  page  793. 

25.  Dumesnil,  vide  Auvray  {loc.  cit.). 

E. 

26.  Ewald,  "  Lectures  on  Diseases  of  the  Stomach,"  "  N.  Sydenham  Soc. 
Trans.,"  1892,  p.  504.     (Cases  reported  from  clinic  of  Frerichs.) 

F. 

27.  Fagge,  "A  Case  of  Diffused  Suppurative  Inflammation  of  the  Stomach," 
"Trans.  Path.  Soc,"  London,  1874-75,  vol.  xxvi,  p.  81. 

28.  Feroci,  "  Ann.  univ.  di  med.  e  chir.,"  Milano,  1873. 

29.  Ferraresi,  "  Sulla  Gastrite  Flemmonoso,"  "  Atti  Accad.  med.  di  Roma." 
1887,  series  Xi,  vol.  cxi,  p.  267. 

30.  Flint,  quoted  by  Reinking  {loc.  cii.),  S.  16,  "Phila.  Med.  Times,"  Aug.  8, 
1878. 

31.  Fontain,  "  Gastrite  Phlegmoneuse,"  "  Bull,  et  mem.  Soc.  med.  d.  hop.  de 
Paris,"  1866,  tome  xi,  p.  131. 

32.  Frankel,  "  Ueber  einen  Fall  von  Gastritis  acuta  emphysematosa, 
wahrscheinlich  mykotischen  Ursprungs,"  "  Virchow's  Archiv,"  1889,  Bd. 
cxviii,  S.  526. 

G. 

34.  Garel,  cited  by  Reinking,  1879  i^^'^-  '^^^O-  S.  17,  "  Lyon  med.,"  Oct.,  187 1. 

35.  Gaudy,  "  Observation  de  Gastrite  Phlegmoneuse,"  "  Archiv  Med.  Beige," 
Bruxelles,  1863,  tome  xxxi,  pp.  459-464. 

36.  Gilbert  and  Dominici,  "  Med.  Jour.,"  New  York,  May,  1894;  cited  from 
Leith's  article  {loc.  cit.). 

37.  Glaser,  "  Zwei  Falle  von  Gastritis  phlegmonosa  idiopathica,"  "  Berl.  klin. 
Wochenschr.,"  1883,  Bd.  xx,  S.  790.     (Two  cases.) 

38.  Glax,  "Ueber  Gastritis  phlegmonosa,"  "Berl.  klin.  Wochenschr.,"  1879, 
Bd.  XVI,  S.  565. 

39.  Glax,  "  Die  Magenentziindung,"  "  Deutsche  med.  Ztg.,"  Berlin,  1884, 
Nr.  3. 

40.  Guyot,  "Gastrite  Phlegmoneuse,"  "Union  med.,"  Paris,  1865,  N.  S., 
tome  XXVII,  pp.  1S4,  185. 

H. 
41  {a).  Habershon,  "Case  of  Suppuration  in  the  Coats  of  the    Stomach," 
"Guy's  Hosp.  Rep.,"  London,  1855,  p.  115. 


484  CHRONIC    GASTRITIS. 

41  {b).  Hemmeter,  John  C,  "  A  Case  of  Phlegmonous  Gastritis,"  etc.,  "  New 
York  Med.  Rec,"  Sept.,  1897. 

42.  Herzog,  "  Kaspar's  Wochenschr.,"  1839,  S.  813;  quoted  by  Reinking 
{loc.  cit.,  S.  11). 

43.  Heyfelder,  "  Sanitatsbericht  iiber  das  Fiirstenthum  HohenzoUern  Sig- 
maringen  wahrend  des  Jahres  1836,"  "  Schmidt's  Jahrb.,"  Leipzig,  1837,  Bd. 
XVI,  S.  192. 

44.  Hun,  "  Idiopathic  Phlegmonous  Inflammation  of  the  Submucous  Cellu- 
lar Tissue  of  the  Stomach,"  "  N.  Y.  Med.  Jour.,"  1868,  vol.  viii,  p.  18. 

K. 

45.  Kelynack,  "A  Case  of  Diffuse  Phlegmonous  Gastritis,"  "Lancet," 
London,  1896,  March  14th. 

46.  Klaus,  "  Beitrag  zur  Kenntniss  d.  ]\Iagenkrankheiten,"  Inaug.-Diss., 
Erlangen,  1857. 

47.  Klebs,  "  Ueber  infectiose  ^Magenaffectionen,"  "  Allg.  Wien.  med.  Ztg,,'' 
1881,  Nr.  29,  30,  31,  32,  34,  35. 

48.  Krabbe,  "  Tidsker.  f.  Vet.,"  Kjobenhaven,  1872;  and  "Deutsche 
Zeitschr.  f.  Thiermedicin,"  Leipzig,  Bd.  i. 

49.  Krause,  "Ueber  submucose  phlegmonose  eitrige  Magenentziindungen," 
Berlin,  1872,  Inaug.-Diss.,  Kiel,  1874. 

50.  Kurschmann,    "  Magenabscess,"    "Wien.    med.    ^Vochenschr.,"    1880, 

Nr.  14. 

L. 

51.  Lasege,  vide  Auvray  {Joe.  cit.). 

52.  Leith,  "Phlegmonous  Gastritis:  Its  Pathology,  Etiology,  Symptoms,  and 
Treatment,"  "  Edinburgh  Hospital  Reports,"  vol.  iv,  pp.  51-114- 

53.  Leube,  "  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,"  1877,  vol. 

VII,  p.  154. 

54.  Lewandowski,  "  Zur  Casuistik  der  idiopathischen  Gastritis  phlegmo- 
nosa,"  "Berlin,  klin.  Wochenschr.,"  1879,  ^d.  xvi,  S.  568. 

55.  Levvin,  "  Zur  Casuistik  der  Gastritis  phlegmonosa  idiopathica,"  "  Berlin, 
klin.  Wochenschr.,"  1884,  Bd.  xxi,  S.  83. 

56.  Lieutaud,  "  Historia  Anatomica-medica "  (includes  observations  by 
Riolanus,  Baunimus,  and  others),  1767,  tome  i,  p.  2. 

57.  Lindemann,  "  Fall  von  Gastritis  phlegmonosa  diffusa,"  "  Miinch.  med. 
Wochenschr.,"  1887,  Nr.  25. 

58.  Lowenstein,  "  Ueber  Gastritis  phlegmonosa,"  Inaug.-Diss.,  Kiel,  1874. 

59.  Loomis,  "  ]Med.  Rec,"  New  York,  Feb.  15,  1869. 

M. 

60.  Macleod,  "Suppurative  Gastritis,"  "Lancet,"  London,  1887,  vol.  xi,  p. 
1116. 

61.  Malmsten  and  Key,  "  Fall  af  Flegmonos  Gastritis,  Hygeia,"  Stockholm, 
1871,  p.  69. 

62.  Manoury,  "  Infiltration  Purulente  Puerperale  del'Estomac,"  "  Bull.  Soc. 
Anat.  de  Paris,"  1842,  tome  xvii,  p.  175. 

63.  Martin,  "Diseases  of  the  Stomach,"  1895,  p.  277. 

64.  Mascaral,  "  Bull.  Soc.  Anat.  de  Paris,"  1830,  tome  xv,  p.  176. 

65.  Mayor,  "  Absces  Sous-muquex  de  I'Estomac,"  "Bull.  Soc.  Anat.  de 
Paris,"  1840,  tome  xvii,  p.  298. 


LITERATURE    ON    PHLEGMONOUS    GASTRITIS.  485 

66.  Mazet,  "  Phlegmon.  Diffuse  de  rEstomac,"  "  Bull.  Soc.  Anat.  de  Paris," 
1840,  tome  XV,  p.  174. 

67.  Meyer,  "St.  Petersb.  med.  Wochenschr.,"  1892,  No.  40. 

68.  Mintz,  "  Ein  Fall  von  Gastritis  phlegmonosa  diffusa  im  Verlaufe  eines 
Magenkrebses,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Leipzig,  1892,  Bd.  XLix, 
S.  487. 

69.  Morel,  "  Gastrite  Phlegmoneuse,"  "Bull.  Soc.  Anat.  de  Paris,"  1865. 

N. 

70.  Nasse  und  Orth,  "  Virchow's  Archiv,"  Bd.  civ,  S.  584. 

71.  Nielsen,  "  Bradsot  hos  Faaret  (Gastromycosis  ovis),"  "  Tidsker.  f.  Vet.," 
Kjobenhaven,  1887,  pp.  1-21. 

O. 

72.  Odmanson,  "Gastritis  phlegmonosa  diffusa,"  "Forh.  v,  Svens  Lak. 
Sallsk.  Sammank,"  Stockholm,  1865,  p.  265. 

73.  Oser,  "  Realencyclopadie"  :  "  Magenentziindung,"  1887,  Bd.  xi,  S.  412. 

P. 

74.  Page,  "A  Case  of  Gastrostomy  Fatal  on  the  Twenty-third  Day,  from 
Acute  Parenchymatous  Gastritis,"  "  Lancet,"  London,  1833,  vol.  11,  p.  53. 

75.  Petersen,  "Ein  Fall  von  Gastritis  phlegmonosa,"  "St.  Petersb.  med. 
Wochenschr.,"  1879,  Bd.  iv,  S.  288. 

76.  Pilliet,  "Bull.  Soc.  Anat.  de  Paris,"  1893,  No.  12. 

R. 

']'] .  Rakowak,  Duchek's  Klinik;  "  Wien.  med.  Presse,"  1873,  Nr.  25. 

78.  Raynaud,  "  De  I'lnfiltration  Purulence  de  I'Estomac,"  "  Bull.  Soc.  Anat. 
de  Paris,"  1861,  tome  vi,  pp.  62-93. 

79.  Reinking,  "  Beitrag  zur  Kenntniss  der  phlegmonosen  Gastritis,"  Inaug.- 
Diss.,  Kiel,  1890,  S.  26. 

80.  Robel,  P.,  Opera,  1656. 

S. 
81;  Sand,  "  Dissertatio  de  raro  Ventriculi  Abscessu  Regiomont,"  1701. 

82.  Sebillon,  "  De  la  Gastrite  phlegmonosa,"  "These  de  Paris,"  1885. 

83.  Sestier,  "  Abscess  Metastatique  des  Parois  de  I'Estomac,"  "Bull.  Soc. 
Anat.  de  Paris,"  1883,  tome  viii,  p.  130. 

84.  Silcock,  "Stomach  Exhibiting  the  Condition  known  as  Phlegmonous 
Gastritis,"  "Trans.  Path.  Soc,"  London,  i882-'83,  vol.  xxxiv,  p.  90. 

85.  Smirnow,  "  Ueber  Gastritis  membranacea  und  diphtheritica,"  "  Virchow's 
Archiv,"  1889,  Bd.  CXIII,  S.  333. 

86.  Smith,  "Med.  Rec,"  New  York,  Oct.  12,  1889. 

87.  Stewart,  "  A  Case  of  Gastritis  Phlegmonosa,  with  Inflammation  and 
Gangrene  of  the  Gall-bladder,"  "  Edin.  Med.  Jour.,"  1868,  N.  S.,  vol.  xii, 
P-  732. 

88.  Strieker  und  Kooslakoff,  "  Experimente  liber  Entziindungen  des  Ma- 
gens,"  "  Sitzungsb,  d.  k.  Akad.  d.  Wissensch.,"  Wien,  i866,',Bd.  Liii. 

T. 

89.  Testi,  Alberico,  "  Un  raro  caso  di  ascesso  dello  stomaco,"  "Anna!  univ. 
di  med.  e  chir.,"  Milano,  Dec,  1883,  pp.  523-547. 

90.  Thoman,  "  AUgem.  Wiener  Zeitung,"  1891,  Nr.  10. 


486  ULCER   Oif    THE    STOMACH. 

91.  Thungel,  "  Ein  Fall  von  Vereiterung  des  submucosen  Zellgewebes  des 
Magens,"  "  Virchow's  Archiv,"  1865,  Bd.  xxxiii,  S.  406-408. 

92.  Treuberg,    "Primary   Phlegmonous    Inflammation    of   the    Stomach," 
"  Vratch,"  St.  Petersburg,  1883,  vol.  LV,  p.  355. 

V. 

93.  Varandaeus,  "  Tractatus  de  Morbis  Ventriculi,"  1620. 

94.  Vorwaltner,  "  Eph.  Nat.  cur.,"  Dec.  3,  Obs.  142. 

W. 

95.  Wallmann,  "Wiener  med.  Wochenschr.,"  1857,  Bd.  xili,  S.  733. 

96.  Whipham,  "  Remarks  on  a  Case  of  Phlegmonous  Gastritis,"  "  Brit.  Med. 
Jour.,"  London,  1884,  vol.  I,  p.  896. 

97.  Wilks  and  Mokon,  "Pathological  Anatomy,"  3d  edition,  1889,  p.  399. 

Z. 

98.  Ziegler,  "  Pathologische  Anatomie,"  Bd.  11,  S.  513. 


CHAPTER  III. 
ULCER  OF  THE  STOMACH. 


Ulcus  Ventriculi,  Pepticum,  Rotundum,  Perforans,  Rodens,  Corro- 
sivurn,  e  Digestione. 

Ulcer  of  the  stomach  is  a  loss  of  substance  of  the  gastric  mucosa, 
characterized  by  very  little  tendency  toward  healing,  but  rather  by 
destructive  progression  both  in  a  lateral  direction — i.  e.,  in  a  plane 
with  the  surface — and  toward  the  depth  of  the  mucosa.  It  may 
occur  in  two  forms,  (i)  the  acute  and  (2)  the  chronic.  The  acute 
form  extends  so  rapidly  from  the  mucosa  toward  the  peritoneum, 
with  such  small  lateral  involvement,  that  Rokitansky's  original 
comparison,  "as  if  the  ulcer  were  cut  out  with  a  punch,"  has  become 
the  classical  expression  of  the  text-books.  In  the  chronic  form  the 
destructive  process  is  not  so  rapid;  it  extends  more  laterally,  pro- 
ducing a  terraced  or  shelving  appearance  of  the  edges  and  sides,so 
that  it  may  be  funnel-shaped.  Perforation  into  an  artery,  vein,  or 
into  the  peritoneal  cavity  occurs  in  both  forms.  The  chronic  form 
has  a  tendency  to  healing,  but  in  so  doing  causes  cicatricial  contrac- 
tions and  deformity.  The  acute  form  may  terminate  in  healing, 
but  owing  to  its  limited  lateral  extent,   the  small   cicatrix   rarely 


SELF-DIGESTION   OF   THE   STOMACH.  487 

causes  deformity.  It  is  very  probable  that  the  acute  ulcers  have  a 
different  etiology  (corrosives,  toxic  action,  trauma  by  sharp,  hard 
materials  in  the  food,  in  conjunction  with  other  factors  to  be  con- 
sidered) from  the  chronic  eroding  type,  to  which  the  following 
description  appertains  more  especially. 

Self-digestion  of  the  Stomach  (Gastromalacia). — If  an  animal 
be  killed  while  in  full  digestion,  the  stomach  may  undergo  'self- 
digestion  after  death  if  the  body  is  kept  warm.  In  human  beings 
who  died  suddenly  while  the  gastric  digestion  was  at  its  height,  it 
was  found  at  the  autopsy  that  not  only  the  stomach  had  been  di- 
gested, but  also  the  spleen,  and  that  this  process  had  extended  through 
the  diaphragm  into  the  lungs.  The  question  naturally  arises.  What 
protects  the  stomach  from  autodigestion  from  its  own  secretions 
under  normal  conditions?  This  is  an  inquiry  that  concerns  the 
fundamental  properties  of  living  matter,  for  it  includes  the  non- 
digestion  of  the  intestinal  tract  by  the  alkaline  pancreatic  juice  and 
succus  entericus,  the  same  property  as  observed  in  the  digestive 
tracts  of  invertebrates  and  even  in  the  unicellular  organisms,  the 
amebse  and  plasmodia  of  mycetozoa.  For  instance,  Metschnikoff, 
C.  Le  Dantec,  Greenwood,  Saunders,  and  the  author  have  shown 
that  a  secretion  is  formed  in  the  digestive  vacuoles  of  these  unicellular 
organisms  which  digests  foreign  proteid  material,  but  not  the  living 
substance  of  the  cell  itself  (see  ' '  On  the  Role  of  Acid  in  the  Digestion 
of  Certain  Rhizopods,"  by  J.  C.  Hemmeter,  Philos.  D.,  etc.,  in 
"American  Naturalist,"  August,  1896,  p.  619). 

The  following  explanations  have  been  offered  for  the  protection 
of  the  human  stomach  from  its  own  secretion: 

1.  By  Hunter:  That  the  principle  of  life  in  living  things  protected 
the  stomach  from  digestion. 

Bernard  succeeded  in  demonstrating  that  the  hind  leg  of  a  living 
frog,  introduced  into  a  dog's  stomach  through  a  fistula,  undergoes 
digestion.  This  will  also  happen  if  the  leg  be  placed  in  a  vessel 
containing  gastric  juice  at  the  proper  temperature. 

2.  Bernard  explained  the  exemption  of  the  normal  stomach  from 
autodigestion  by  assuming  a  protective  power  in  the  living  epi- 
thelium, which  he  thought  prevented  the  absorption  of  gastric  juice. 

3.  Strieker  believed  that  the  mucus  formed  on  the  surface  of  the 
stomach  acts  as  a  protective  covering. 

4.  Pavy  ("Guy's  Hospital  Reports,"  vol.  xiv,  1868)  held  that  the 
alkaline  blood  circulating  through  the  gastric  walls  saved  them  from 


ULCER  OF  The;  stomach. 

digestion,  since  it  neutralized  the  acid  as  fast  as  it  was  absorbed. 
None  of  these  explanations  is  sufficient.  Bernard's  suggestion 
simply  shifts  the  problem  by  assuming  an  immunity  of  the  living 
epithelial  cells  without  attempting  to  explain  why  these  are  not 
digested.  The  coating  of  mucus  which  Strieker  believed  to  be  a 
protection  is  digested  by  gastric  juice. 

Pavy's  theory  that  the  alkaline  reaction  of  the  gastric  circulation- 
prohibits  self-digestion,  is  untenable,  because  under  these  conditions 
one  could  not  explain  why  the  pancreas  does  not  digest  itself,  and 
is  also  disproved  by  Samelson,  who  produced  a  neutral  reaction  of 
the  blood  by  gradual  introduction  of  acid,  and  then  poured  dilute  HCl 
into  the  animals'  stomachs;  but  even  then  no  autodigestion  was 
observed.  When  Hunter,  over  one  hundred  years  ago  (1786),  re- 
ferred the  immunity  to  a  specific  property  of  the  living  cells,  the 
"vital  principle,"  he  gave  as  good  an  explanation  as  any  given  up 
to  date.  The  expression  "vital  principle"  may  sound  mysterious 
in  the  light  of  modern  physiological  knowledge,  but  it  undoubtedly 
implied  that  gastric  immunity  from  self-digestion  was  due  to  physical 
and  chemical  forces  possessed  by  the  protoplasm  of  living  cells  and 
which  are  not  as  yet  understood.  In  the  latter  term  we  use  more 
accurate  expressions,  but  give  no  better  explanation  than  Hunter. 

Elsasser  agreed  that  gastromalacia  was  always  a  cadaverous  pro- 
cess, and  was  supported  in  this  view  by  Virchow,  Foster,  Oppolzer, 
Bamberger,  and  others,  so  that  his  opinion  became  the  prevailing 
one.  A  contrary  view  was  held  by  Rokitansky,  who  represents  the 
belief  that  there  is  a  gastromalacia  that  occurs  intra  vitam,  particu- 
larly in  the  end  stages  of  grave  diseases  of  the  brain  and  its  mem- 
branes (basal  and  tuberculous  meningitis)  and  in  other  severe  ex- 
hausting affections.  The  occurrence  of  intravital  autodigestion  was 
proved  in  a  case  reported  both  by  W.  Mayer  and  Leube  from 
Ziemssen's  clinic,  and  also  by  numerous  animal  experiments. 

Results  of  animal  experiments  in  producing  secondary  injury  and 
consequent  self-digestion  of  the  stomach  are  the  following :  Schiff ,  by 
intersection  of  the  thalami  and  cerebral  peduncles,  produced  hemor- 
rhagic infiltrations,  partial  softenings,  erosions,  and  even  ulcer  forma- 
tion in  the  gastric  mucosa,  and  interpreted  his  results  as  conse- 
quences of  neuroparalytic  hyperemia  caused  by  injury  to  the  central 
vasomotor  nerve-tracks  of  the  stomach.  Ebstein  and  Brown- 
Sequard  obtained  identical  effects  after  circumscribed  destruction 
of  the  anterior  corpora  quadrigemina.     Panum  injected  an  emulsion 


EXPERIMENTS    BEARING    ON   THE    ETIOEOGY.  489 

of  tinv  wax  globules  into  the  femoral  arteries  of  dogs  and  effected 
small  gastric  hemorrhagic  infarcts  and  ulcers.  Cohnheim  infected 
suspensions  of  plumbic  chromate  into  the  stomach  circulation,  by 
which  he  succeeded  in  blocking  only  the  branches  of  the  mucosa 
and  submucosa,  while  the  circulation  of  the  muscularis  remained  free. 
At  the  autopsy  he  discovered  large  ulcers  with  abruptly  descending 
■edges  and  clean  bases.  Koch  and  Ewald  brought  about  gastric 
hemorrhagic  infarcts  by  intersection  of  the  spinal  cord  (Schiff's 
method),  and  after  this  introduced  strong  solutions  of  hydrochloric 
acid  (5  per  1000)  into  the  stomach,  thereby  producing  penetrating 
ulcerations.  After  severe  traumatism, — for  example,  bruising  the 
epigastric  region  with  a  hammer, — and  after  thermic  irritation,  as 
by  introducing  very  hot  gruel,  Ritter  and  Decker  produced  ulcus 
ventriculi.  Silbermann  brought  on  gastric  ulcers  that  healed  with 
difficulty  by  causing  hemoglobinemia  with  substances  that  dissolved 
the  blood-corpuscles. 

His  results  are  significant,  as  explaining  the  pathogenesis  of  gas- 
tric ulcer  after  extended  skin  burns  and  malaria.  This  is  to  a  certain 
extent  explained  by  the  investigations  of  Klebs  and  Welti,  who  have 
showji  that  broken-down  red  corpuscles,  blood-pigment  and  thrombi 
of  blood-plaques,  or  undeveloped  elements  may  occlude  the  gastric 
vessels  and  cause  ulcer;  and  lyondon  explains  the  gastric  ulcers  in 
malaria  by  the  occurrence  of  pigment  emboli.  Talma  produced 
gastromalacia  and  gastric  ulcers  by  ligating  the  esophagus  of  dogs 
above  the  cardia  and  the  duodenum  below  the  pylorus  (Talma, 
"Untersuch.  iiber  Ulcus  ventric,"  etc.,  "Zeitschr.  f.  klin.  Med.," 
Bd.  XVII,  S.  10).  This  experiment  constitutes  too  violent  an  inter- 
ference with  normal  gastric  physiology  to  permit  of  any  correct 
deductions. 

It  is  impossible  to  differentiate  the  effects  of  violent  trauma,  inter- 
ference with  the  venous,  arterial,  and  lymph-supply,  intragastric 
stagnation,  fermentation,  and  sepsis,  that  the  experiment  of  Talma 
brings  about. 

Views  Concerning  Causative  Circulatory  Disturbances. — 
Virchow  called  attention  to  the  frequency  of  gastric  ulcers  in  anemia 
and  chlorosis,  explaining  it  by  the  diseases  of  the  vessel  walls,  fatty 
degenerations,  aneurysmal  and  varicose  dilatations,  and  their  con- 
sequences, viz. :  thrombosis  and  embolism.  Cohnheim  conceded  the 
casual  relations  of  these  states,  but  disputed  the  frequency  of  their 
occurrence,    (i)    because    the    abundant   anastomoses   between   the 


490  ULCER   OF   THE   STOMACH. 

gastric  vessels  facilitate  a  compensatory  collateral  circulation;  (2) 
because  the  diseases  of  the  vessel  walls  referred  to  are  rare  in  young 
but  frequent  in  old  persons,  which  would  indicate  that  in  these 
gastric  ulcer  should  be  found  frequently,  whereas  in  later  life  it  is  very 
rare.  Kllebs  has  a  theory  attributing  gastric  ulcer  to  local  ischemia, 
supposed  to  be  caused  by  spastic  arterial  contractions.  Rind- 
fieisch's  opinion  is  that  venous  stasis  in  the  gastric  walls  may  lead  to 
ulcer,  since  occlusion  of  the  exit  of  the  blood  may  occur  easily  on 
account  of  the  compressibility  and  the  few  anastomoses  in  the  gastric 
veins;  this,  he  thinks,  may  cause  hemorrhage,  erosions,  and  ulcer. 
Cohnheim  opposes  this  view  also,  because  gastric  ulcer  is  a  rare  thing 
in  the  passive  congestion  due  to  hepatic  cirrhosis.  One  must  not 
overlook  the  fact,  however,  that  in  this  state  the  secretion  of  HCl 
is  much  reduced.  Axel  Key  assumes  that  long  and  persisting 
contractions  of  the  musculature  may  cause  local  ischemias  or  dis- 
turbances in  the  venous  outflow.  From  these  observations  it  is 
clear  that  interruption  of  the  blood-current  in  localized  areas  of  the 
mucosa  may  lead  to  formation  of  ulcer.  The  blood  stream,  then,  is 
a  protective  against  autodigestion,  not  because  it  keeps  the  gastric 
mucosa  alkaline,  as  Pavy  held, — for  the  mucosa  is  acid  throughout 
the  glandular  layer, — but  because  the  blood  keeps  the  mucosa 
nourished  and  alive. 

When  the  internal  surface  of  the  stomach  is  no  longer  nourished, 
it  must  die  in  areas,  which  are  then  digested,  as  other  dead  proteid 
matter  would  be. 

The  degree  of  alkalinity  of  human  blood  is  far  too  low  to  neu- 
tralize the  degree  of  HCl  acidity  present  in  any  part  of  the  mucosa. 

The  digestion  of  the  hind  leg  of  a  live  frog  (Bernard)  in  the  stomach 
of  an  animal  does  not  prove  that  living  tissue  will  be  digested  there. 
For  the  cells  of  cold-blooded  animals  die  rapidly  at  the  temperature 
of  the  warm-blooded  animal ;  furthermore,  the  epidermis  of  the  frog's 
leg  may  be  killed  by  the  HCl,  and  once  dead,  it  is  rapidly  digested. 

Bottcher  and  lyCtulle  attribute  the  causation  of  ulcer  to  bacteria, 
which  they  could  demonstrate  in  colonies  in  the  floor  and  in  the 
surroundings  of  ulcer. 

Most  of  the  observers  mentioned  make  the  statement  that  gastric 
ulcers  produced  experimentally  in  animals  heal  rapidly.  The  mucosa 
is  replaced  almost  completely ;  a  new  formation  of  peptic  glands  has 
been  observed  by  Grifinni,  Hauser,  and  Vassali.  At  autopsies, 
cicatrices  are  often  found  in  the  human  stomach,  where  no  symptoms 


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ETIOLOGY   OF   PEPTIC   ULCER.  49 1 

referable  to  ulcer  were  evident  during  life.  It  is  known,  also,  that 
pieces  have  been  torn  loose  by  the  suction  of  the  lower  end  of  the 
stomach-tube ;  and  yet  this  loss  of  substance  healed  without  forming 
an  ulcer;  so  that  repair  may  follow  injury  to  the  human  stomach, 
and  it  is  very  evident  that  some  other  causatory  factors  besides  injury 
are  necessary  to  bring  about  an  ulcer.  A  pathological  composition 
of  the  blood  has  been  thought  to  be  one  of  these  factors,  particularly 
as  gastric  ulcer  is  very  frequently  found  in  anemia  and  chlorosis. 
I  have  analyzed  the  gastric  contents  of  32  cases  of  chlorosis — of 
these,  24  had  marked  hyperacidity;  in  6  the  acidity  was  normal  and 
in  2  it  was  subnormal.  This  frequent  coexistence  of  hyperacidity 
with  chlorosis  has  been  observed  by  Riegel,  Cantu,  and  Bouveret, 
and  is  important  for  the  etiology.  This  view  is  supported  by  the 
experiments  of  Quincke  and  Daettwyl^r,  who  produced  a  high  degree 
of  anemia  by  gradual  withdrawal  of  blood  from  dogs.  Thereafter, 
they  produced  gastric  injuries  by  mechanical,  chemical,  and  thermic 
irritants,  and  discovered  that  ulcers  were  formed  that  healed  with 
much  difficulty.  Clinical  experience  confirms  these  observations, 
that  an  impaired  state  of  the  blood  may  greatly  protract  healing. 
On  the  other  hand,  there  are  numerous  records  of  severe  and  recur- 
rent attacks  of  gastric  ulcer  in  persons  whose  blood  was  found  per- 
fectly normal. 

Etiology. — The  deductions  from  the  preceding  summary  of  ex- 
periments and  observations  are,  above  all,  the  establishing  of  four 
principal  factors  in  the  etiology  of  ulcer: 

I.  An  impaired  vitality  or  resistance  of  portions  of  the  mucosa. 
II.  Hyperacidity  or  supersecretion. 

III.  An  altered  state  of  the  blood. 

IV.  Local  bacterial  infection. 

There  are  a  number  of  well-authenticated  cases  on  record,  proving 
that  direct  trauma  may  cause  gastric  ulcer  (vide  Einhorn,  loc.  cit., 
p.  191 ;  also  others  reported  by  C.  Hoffmann,  Leube,  and  Hichhorst). 

According  to  Sidney  Martin  {loc.  cit.,  p.  410),  there  are  three 
common  causes  of  the  death  of  the  tissue  which  precedes  ulceration : 

I .  Mechanical  and  Chemical  Causes. — Ingested  fish-bones,  ^gg  and 
oyster  shells,  seeds,  etc.  Corrosive  poisons  lead  to  ulceration  by 
directly, destroying  the  tissue;  and  an  injury  to  the  mucous  mem- 
brane, which  is  subsequently  exposed  to  the  continued  action  of  an 
irritant,  will  also  lead  to  an  ulcer. 

Direct  injury  and  wounding  of  the  gastric  mucosa  occurs  very 


492  UIvCER   OF   THE   STOMACH. 

frequently,  and,  as  a  rule,  heals  very  rapidly.  There  are  a  number 
of  cases  on  record  of  persons  swallowing  glass,  nails,  and  knives, 
which  passed  through  the  entire  intestine  without  causing  injury. 
Marcet  ("Med.  Chirur.  Transactions,"  vol.  xn,  p.  72)  narrates  the 
case  of  an  American  sailor  swallowing  some  thirty  pieces  of  knife- 
blades,  which  were  found  in  his  stomach,  together  with  a  number  of 
handles.  Two  blades  were  in  the  colon  and  rectum,  placed  trans- 
versely, and  had  perforated  the  intestinal  wall  without  causing 
peritonitis.     No  recent  or  old  ulcers  were  found  in  the  stomach. 

The  following  report  from  the  German  Hospital  of  Kansas  City 
goes  to  show  that  this  class  of  human  ostrich  has  not  died  out.  The 
main  fact  that  is  proved  by  such  cases  is  that  something  else  is 
needed  in  addition  to  direct  injury  to  the  stomach  in  order  to  pro- 
duce an  ulcer. 

German  Hospital,  Kansas  City,  Mo.,  June  14,  1897. — Harry  Whallen,  the 
"  human  ostrich,"  who  was  operated  upon  at  the  German  Hospital  last  Satur- 
day, and  from  whose  stomach  the  surgeon  took  an  assortment  of  cutlery  and 
hardware,  died  at  two  o'clock  this  morning,  the  result  of  the  operation. 

Whallen  got  into  trouble  by  swallowing  a  big  Barlow  knife,  in  Pilot  Grove, 
Mo.  When  he  was  operated  upon  at  the  German  Hospital  these  articles  were 
removed  from  his  stomach  : 

Two  jack-knives,  one  3  inches  long  and  the  other  4  inches ;  5  knife-blades, 
from  I  to  3  inches  long;  32  wire  nails,  eightpenny  or  larger;  34  sixpenny 
nails,  26  shingle  nails,  16  carpet  tacks  and  small  wire  nails,  i  barbed  wire 
staple,  I  horseshoe  nail,  3  screws,  3  ounces  of  glass,  and  several  bits  of  crockery. 

He  was  a  professional  showman.  He  began  swallowing  glass  and  nails 
when  he  was  ten  years  old,  and  says  he  has  eaten  a  lamp  chimney  nearly 
every  day  during  the  seventeen  years  he  has  been  at  it,  but  the  Barlow  knife, 
which  he  swallowed  last  week,  was  too  much,  even  for  his  long-suffering 
stomach. 

When  the  surgeons  operated  upon  him,  the  stock  of  hardware  inventoried 
was  found  imbedded  in  a  solid  mass  in  his  stomach  and  partially  encysted. 
After  it  was  removed,  the  stomach  was  thoroughly  washed  out  and  sewed  up. 

2.  Interference  with  the  Vitality  of  the  Tissue. — The  vitality  of  a 
particular  part  of  the  mucous  membrane  may  be  diminished  by 
local  and  chronic  disease  or  by  interference  with  the  circulation  over 
a  certain  area.  This  latter  usually  occurs  by  means  of  thrombosis 
or  embolism.  Thrombosis  takes  place  in  connection  with  disease 
of  the  vessels  and  in  association  with  inferior  quality  of  the  blood 
and  a  slowing  of  the  local  circulation;  embolism  'may  be  infective 
or  non-infective,  and  is  usually  capillary. 

3.  Bacterial  Infection. — The  infective  processes  of   the   digestive 


BACTERIAL   INFECTION.  493 

mucosa  with  which  we  are  most  famiHar  are  the  ulceration  processes 
of  typhoid  fever,  certain  dysenteries,  and  tuberculosis.  In  the  gas- 
tric ulcer,  however,  there  is  another  kind  of  bacterial  infection, 
which  is  not  accompanied  with  the  signs  of  active  inflammation, 
and  is  termed  by  some  authors  "bacterial  necrosis." 

The  process  is  characterized  by  the  invasion  of  bacteria,  usually 
in  the  lower  depths  of  the  mucous  membrane,  by  their  growth  and 
subsequent  necrosis  of  the  tissue.  Although  the  secretion  of  HCl 
is  germicidal  to  many  bacteria,  it  must  be  remembered  that  the 
spores  are  not  destroyed  by  it,  and  that  the  invasion  may  take 
place  during  the  periods  of  rest  of  the  glands  in  the  intervals  of 
digestion  when  no,  or  very  little,  HCl  is  secreted.  There  is  room 
for  the  suggestion  that  the  primary  necrosis  is  due  to  bacteria  and 
the  ensuing  ulceration  caused  by  the  action  of  the  gastric  juice. 
The  bacteria  can  exist  in  the  cells  around  and  beneath  the  floor  of 
the  ulcer,  and  notwithstanding  a  very  high  degree  of  hyperacidity. 

In  a  number  of  cases  which  I  examined  by  the  most  approved 
cellular  and  bacterial  stains  the  bacteria  were  present  throughout 
the  layers,  even  in  the  peritoneum,  while  the  floor  of  the  ulcer  was 
in  the  muscularis.  It  is  conceivable  that  they  pave  the  way  for 
autodigestion  by  causing  necrosis  of  the  tissues  in  which  they  are 
imbedded.  No  bacterium  was  so  far  obtained  in  pure  culture,  but 
the  one  most  frequently  observed  was  a  bacillus  very  much  resem- 
bling that  of  anthrax,  and  in  two  cases  of  ulcus  carcinomatosum  the 
Oppler-Boas  bacillus. 

Thermic  causes  are  the  ingestion  of  very  hot  food  and  drink,  taken 
when  the  organ  is  empty. 

An  interesting  etiological  relation  exists  between  cutaneous  burns 
and  gastric  or  duodenal  ulcers. 

The  last  two  factors,  hot  food  and  large  cutaneous  burns,  are 
given  in  explanation  of  the  reported  frequency  of  gastric  ulcer  among 
cooks,  who  are  in  the  habit  of  tasting  foods  that  are  still  on  the  fire, 
and  who  are  also  liable  to  frequent  burns.  However,  there  is  no 
satisfactory  statistical  evidence  that  gastric  ulcer  is  more  frequently 
diagnosed  in  cooks  than  in  other  trades. 

Constitutional  causes  are  generally  brought  about  by  such  diseases 
as  effect  alterations  and  degeneration  either  in  the  composition  of  the 
blood  or  in  the  vessels.  These  are  chlorosis,  anemia,  syphilis,  tuber- 
culosis, arteriosclerosis;  fatty,  amyloid,  and  aneurysmal  degenera- 
tions of  arteries;  thrombi,  emboli,  trichinosis,  and  malaria. 


494 


ULCER    OF    THE    STOMACH. 


Effect  of  pressure  exerted  upon  the  stotnacli  by  the  costal  margins 
is  claimed  to  induce  anemia  and  atrophy  of  the  mucosa,  especially 
in  the  region  of  the  smaller  curvature.  Habershon  and  Rasmussen 
have  advanced  this  view,  in  explanation  of  the  frequency  of  gastric 
ulcer  in  those  whose  occupations  necessitate  continual  pressure  on 
the  stomach. 

Influence  of  Age. — In  order  to  determine  from  postmortem  records 
the  age  at  which  gastric  ulcer  most  frequently  occurs,  all  cases  in 
which  only  cicatrices  are  found  should  be  excluded,  because  a  cica- 
trix gives  no  evidence  as  to  the  age  at  which  the  ulcer  existed.  The 
best  statistics  on  this  subject  are  contained  in  Welch's  article  on 
Gastric  Ulcer  in  Pepper's  "System  of  Medicine,"  volume  ii,  page 
483.  The  statistics  of  Brinton,  which  are  still  cited  in  the  last 
editions  of  Boas,  Fleischer,  Sidney  Martin,  Fleiner,  Debove  and 
Remond,  and  others,  include  all  cicatrices  found  at  autopsies  as  open 
ulcers.  The  following  table  is  given  by  Welch,  representing  the  age 
in  607  cases  of  open  ulcer,  collected  from  hospital  statistics: 


Age,  . 

I-IO 

10-20 

20-30 

30-40 

40-50 

50-60 

60-70 

70-80 

80-90  90-100   j^"" 

No.  of 
Cases, 

I 

32 

119 

107 

114 

108 

84 

35 

6 

0          I 

^                    J 

^                       , 

, 

, '                                  , 

Totals, 

33 

226                    222                     119           i                 7 

From  this  table  it  is  apparent  that  the  largest  number  of  cases  is 
found  between  twenty  and  thirty.  Three-fourths  of  the  cases  occur 
between  twenty  and  sixty. 

In  41,688  cases,  constituting  the  clinical  material  in  Zurich  and 
Breslau  between  the  years  1853  and  1873,  252  cases  of  gastric  ulcer 
were  diagnosed  during  life  by  Tebert;  nearly  seven-tenths  were  be- 
tween twenty  and  forty  years  of  age, — a  preponderance  sufficiently 
great  to  be  of  diagnostic  value  in  the  differentiation,  as  we  shall  see 
later  from  carcinoma,  for  in  this  disease  the  largest  number  of  cases 
is  found  between  fifty  and  sixty  years.  Goodhart  has  described  a 
case  of  gastric  ulcer  in  an  infant  thirty  hours  old. 

Influences  of  Sex. — Females  are  more  frequently  affected  than 
males;  the  following  are  the  figures  given  by  various  authors: 


THE  FREQUENCY  OF  GASTRIC  ULCER.  495 

Males.  Females. 

Welch, 40  per  cent.  60  per  cent,  in  1699  cases  of  gastric  ulcer 

found  at  autopsy. 

Brinton's  ratio,       .    .     I  male  to  every  2  females. 

Anderson, 3  males  and  32  females  in  35  cases. 

Habershon,    ....  74  males  and  127  females  in  201  cases. 

Steiner's  ratio,  ...     8  males  to  11  females. 

The  nursing  period,  puerperium,  and  menstruation  are,  it  is  claimed, 
liable  to  increase  the  susceptibility  to  ulcer. 

Geographical  Distribution. — There  seems  to  be  an  unequal  geo- 
graphical distribution  of  the  disease,  which  seems  to  be  more  common 
in  northern  than  in  southern  countries.  It  is  less  common  in  this 
country  than  in  England  and  Germany,  according  to  Da  Costa,  Keat- 
ing, and  Welch  iloc.  cit.,  p.  485).  The  last-mentioned  author  found 
only  six  cases  of  gastric  ulcer  in  800  autopsies  made  by  him  in  New 
York.  In  444,564  deaths  in  New  York  City,  from  1868  to  1882,  ulcer 
of  the  stomach  was  assigned  as  the  cause  in  only  410  cases.  To  these 
statistics  little  importance  can  be  attached,  because  they  are  compiled 
from  reports  of  practitioners  of  varying  diagnostic  skill,  and  concern 
a  disease  that  presents  many  difficulties  of  recognition. 

The  Frequency  of  Gastric  Ulcer. — We  quote  the  following  from 
Professor  Welch's  article  {loc.  cit.) : 

In  32,052  autopsies  made  in  Prague,  Berlin,  Dresden,  Erlangen,  and 
Kiel,  there  were  found  1522  cases  of  open  ulcer  or  of  cicatrix  in  the 
stomach.  If  all  the  scars  be  reckoned  as  healed  ulcers,  according  to 
these  statistics  gastric  ulcer,  either  cicatrized  or  open,  is  found  in 
about  five  per  cent,  of  persons  dying  from  all  causes. 

It  is  important  to  note  the  relative  frequency  of  open  ulcers  as  com- 
pared with  that  of  cicatrices.  In  1 1,888  bodies  examined  in  Prague, 
there  were  found  164,  or  1.4  per  cent.,  with  open  ulcers,  and  373,  or 
3.1  per  cent.,  with  cicatrices.  Here  scars  were  found  about  two  and 
one-fourth  times  as  frequently  as  open  ulcers.  The  observations  of 
Griinfeld  in  Copenhagen  show  that  when  especial  attention  is  given  to 
searching  for  cicatrices  in  the  stomach,  they  are  found  much  more 
frequently  than  the  figures  here  given  would  indicate.  It  would  be  a 
moderate  estimate  to  place  the  ratio  of  cicatrices  to  open  ulcers  at 
three  to  one. 

The  statistics  concerning  the  average  frequency  of  open  ulcers  are 
much  more  exact  and  trustworthy  than  those  relating  to  cicatrices. 
It  may  be  considered  reasonably  certain  that,  at  least  in  Europe,  open 
gastric  ulcers  are  found,  on  the  average,  in  from  one  to  two  per  cent, 
of  persons  dying  from  all  causes. 


496  UIvCER    OF    THE   STOMACH. 

It  is  manifestly  impossible  to  formi  an  accurate  estimate  of  the  fre- 
quency of  gastric  ulcer  from  the  number  of  cases  diagnosed  as  such 
during  life,  because  the  diagnosis  is  in  many  cases  uncertain.  Hence 
the  importance  of  autopsy  statistics. 

Von  Jaksch  (cited  by  Bamberger,  "Handbuch  d.  speciel.  Path.  u. 
Therap.,"  von  Virchow,  vi,  i.  Abth.,  280)  states  that  113  ulcers  or 
cicatrices  were  found  in  2330  autopsies,  i.  e.,  4.8  per  cent.  Orth  gives 
five  per  cent. 

Berthold's  statistics  from  the  "Charite,"  Berlin,  from  1868  to  1882, 
give  294  cases, — 2.7  per  cent.  ("Statist.  Beitrage  z.  Kennt.  d.  chron- 
ischen  Magengeschwiirs,"  Sections-Protocoll  d.  Path.  Inst.,  Berlin). 

Nolte,  Miinchen,  1876  to  1883,  gives  3500  autopsies,  with  43  ulcers, 
or  1.23  per  cent.  ("Haufigkeit  d.  Magengeschwiirs  in  Miinchen,"  Dis- 
sert., 1883). 

Berthold  (cited  from  Ewald,  "Diseases  of  the  Stomach,"  p.  233) 
gives  the  percentage  of  ulcer  of  the  stomach  for  Berlin  as  2.7  per  cent. ; 
Nolte,  for  Munich,  as  1.23;  Gries,  for  Kiel,  as  8.3;  Stark,  for  Copen- 
hagen, as  13  per  cent.  Von  Sohlern  ("Der  Einfluss  der  Ernahrung 
auf  die  Entstehung  des  Magengeschwiirs,"  "Berlin,  klin.  Wochen- 
schr.,"  1889,  No.  14)  has  lately  called  attention  to  the  fact  that  the 
Roen  Mountains  and  the  Bavarian  Alps  (Germany)  and  the  greater 
part  of  Russia  are  nearly  exempt  from  gastric  ulcer.  The  diet  upon 
which  the  inhabitants  of  these  countries  subsist  consists  largely  of 
amylaceous  and  A^egetable  substances  containing  a  large  percentage  of 
potassium  salts.  The  blood  of  persons  living  largely  or  exclusively 
on  a  vegetarian  diet  (Japanese)  is  very  rich  in  potassium  phosphate. 
According  to  von  Sohlern,  the  exemption  from  gastric  ulcer  observed 
among  these  peoples  is  due  to  the  large  amount  of  potassium  intro- 
duced in  their  food.  We  are  not  aware  that  von  Sohlern  has  sup- 
ported his  theory  by  quantitative  blood  analyses;  this  constitutes  a 
weak  point  in  his  argument. 

Location  of  Gastric  Ulcer. — This  table  gives  the  situation  of  793 
ulcers  reported  in  hospital  statistics  (from  article  on  "Simple  Ulcer  of 
the  Stomach,"  by  W.  H.  Welch,  M.D.,  Pepper's  "System  of  Medi- 
cine," vol.  11) : 

Lesser  curvature, 288  (36.3  per  cent.) 

Posterior  wall, 235  (29.6    "  ''  ) 

Pylorus, 95  (12  "  "  ) 

Anterior  wall, 69  (  8.7  "  "  ) 

Cardia, 5°  (  6.3  "  "  ) 

Fundus, 29  (   3.7  "  "  ) 

Greater  curvature, 27  (   3.4  "  "  ) 


SYMPTOMATOLOGY.  497 

Symptomatology. — The  most  characteristic  subjective  signs  of 
gastric  ulcer  are  localized  pain,  vomiting,  hematemesis,  disturbances 
of  secretion,  the  presence  of  blood  in  the  stools,  and  the  state  of  the 
appetite.  Frequently  all  these  symptoms  occur  together;  at  other 
times  only  one  or  the  other  single  symptom  becomes  prominent. 
There  are  cases  of  gastric  ulcer  that  run  a  latent  course,  without  any 
characteristic  symptoms  whatever. 

We  will  begin  with  a  consideration  of  the  excessive  secretion  of  HCl. 
This  is  a  result  of  the  irritation  of  the  gastric  nerves,  either  by  the 
inflammation  caused  by  the  ulcer  itself,  or  by  irritation  of  exposed 
nerve-fibers,  caused  by  the  contents  of  the  stomach.  Since  the 
publication  of  the  first  edition  of  this  work,  Prof.  J.  P.  Pawlow  has 
demonstrated  the  secretory  nerves  of  the  stomach  in  the  vagus  and 
sympathetic  by  methods  irreproachable  from  the  standpoint  of 
physiological  technique.  By  admirable  patience  he  succeeded  in 
preparing  such  vagus  fibers  as  caused  only  a  prompt  secretion  of 
gastric  juice  and  others  that  responded  to  stimulation  by  prompt 
inhibition  of  secretion  (Pawlow,  "Arbeit  d.  Verdauungsdriisen, "  S. 
78).  Just  as  the  eye  will  overflow  with  tears  until  an  offending 
foreign  body  has  been  removed,  and  just  as  the  saliva  will  be  secreted 
when  the  mucous  membrane  of  the  mouth  is  stimulated  by  food,  or 
when  there  are  ulcers  or  inflammations  present  in  the  buccal  cavity, 
so  in  a  similar  manner  the  gastric  mucosa  will  respond  to  irritation  of 
its  nerve-fibers  by  an  augmented  secretion. 

The  entire  gastric  nerve  apparatus  is  placed  in  a  state  of  increased 
excitability  through  the  presence  of  an  ulcer,  and  when  food  reaches 
the  stomach  the  mucosa  is  stimulated  to  a  degree  much  greater  than 
in  the  normal  stomach.  The  percentage  of  HCl  present  varies  from 
three  to  five  per  looo;  this  strong  gastric  juice  rapidly  dissolves  albu- 
minous constituents  of  the  food,  while  the  carbohydrates  remain 
undigested.  Organic  acids  are  absent.  It  may  happen,  in  rare 
cases,  that  the  peristalsis  of  the  stomach  is  inhibited,  causing  reten- 
tion of  the  food;  in  such  cases  the  irritation  of  the  nerves  is  kept  up 
as  long  as  food  is  present  in  the  stomach,  constituting  continued 
hypersecretion.  We  have  to  distinguish  in  these  cases  between  two 
kinds  of  excess  of  gastric  juice:  (i)  the  digestive  hyperacidity,  which 
occurs  when  the  motility  is  good,  only  during  the  normal  presence  of 
ingesta  in  the  stomach ;  (2)  the  continued  hypersecretion,  which  occurs 
as  soon  as  the  motility  is  impaired,  when  food  is  present  at  all  times 
in  the  organ.     With  a  continued  hypersecretion  the  glandular  cells 


498  ULCER   OF   THE    STOMACH. 

gradually  become  exhausted ;  they  eventually  secrete  a  juice  which  is 
much  poorer  in  HCl  and  pepsin  than  the  normal  product,  just  as  the 
exhausted  salivary  gland-cells  secrete  a  saliva  which  is  very  poor  in 
ptyalin.  The  exhaustion  of  the  gastric  gland-cells  may  explain  the 
observation  referred  to,  where  hyperacidity  was  absent  in  cases  of  un- 
doubted gastric  ulcer.  The  fact  probably  was,  the  glands  had  be- 
come so  exhausted  by  continued  overwork  that  it  was  impossible  for 
them  to  form  their  characteristic  product. 

The  pain  of  gastric  ulcer  is  caused  by  irritation  of  the  sensory  nerves 
in  the  base  of  the  corroded  area.  It  occurs  with  great  intensity  after 
the  ingestion  of  food,  and,  as  a  rule,  increases  with  the  augmentation 
of  acid  during  digestion.  The  pain  during  the  digestive  act  is  most 
probably  caused  also  by  the  peristaltic  movements,  drawing  upon 
and  compressing  the  ulcer.  External  pressure  will  produce  sharp 
pain  in  the  locality  of  the  ulcer.  The  pain  is  of  a  burning, 
stinging  character,  and  in  some  cases  it  causes  a  spastic  contraction 
of  the  sphincter  of  the  pylorus  reflexly — a  reflex  pylorospasm,  which 
in  itself  may  be  very  painful.  Some  patients  complain  frequently  of 
a  sore  spot  in  the  epigastrium.  In  cases  of  gastric  ulcer  associated 
with  pylorospasm  the  pain  radiates  from  the  epigastrium  toward  the 
right  and  left,  reaching  the  spinal  column.  Traube  called  attention 
to  well-defined  irradiations  of  the  pain  into  the  domain  of  other  nerves 
outside  of  the  stomach.  Attacks  of  angina  pectoris,  intercostal  neu- 
ralgias, and  neuralgias  in  the  left  brachial  plexus  have  been  described 
by  Brinton;  sympathetic  neuralgias  in  the  arms  and  legs  have  been 
referred  to  by  M.  Miiller. 

The  intercostal  nerves  of  the  left  side  may  be  in  a  more  sensitive 
condition  earlier  than  those  of  the  right  side.  This  may  reveal  itself 
by  a  hyperesthesia  of  the  skin  and  soft  parts  in  the  lower  left  parts  of 
the  thorax,  upper  portions  of  the  abdomen,  and  in  the  lumbar  region. 
The  slightest  touch,  the  pressure  of  the  clothes  and  bed-covers,  maybe 
unpleasant  to  such  patients.     Female  patients  can  not  wear  a  corset. 

Very  frequently  the  pain  has  a  penetrating,  lancinating  character, 
shooting  from  the  epigastrium  straight  through  to  the  spinal  column. 
The  influence  of  the  ingestion  of  food  on  the  pain  is  very  evident, 
although  there  are  painful  sensations  when  the  stomach  is  empty; 
these  sensations  partake  more  of  the  nature  of  soreness  and  hunger. 
This  may  be  mqmentarily  relieved  by  the  taking  of  food,  only  to  be- 
come more  severe  by  the  stimulation  and  the  hyperacid  secretion  that 
are  set  up  by  it.     Liquid  food  may  pass  through  the  stomach  without 


PYROSIS.  499 

causing  much  annoyance,  whereas  soHd  food  is  always  distressing. 
Very  cold  or  very  hot  food  invariably  causes  this  gastralgia.  The 
pain  usually  occurs  within  a  half  hour  after  ingestion.  Should  it  not 
occur  until  an  hour  and  a  half  to  two  hours  after  meals,  this  would 
justify  the  suspicion  of  an  ulcer  below  the  pylorus  in  the  duodenum, 
whereas  if  the  pain  occurs  at  once,  during  the  act  of  deglutition,  an 
ulcer  in  the  lower  part  of  the  esophagus  should  be  suspected.  Lying 
on  the  left  side  increases  the  pain  (Leube),  whereas  absolute  quiet  and 
resting  on  the  back  relieve  it. 

Pyrosis. — There  is  in  most  cases  a  very  annoying  burning  feeling 
in  the  left  hypochondrium  and  epigastrium,  frequently  rising  to  the 
throat.  Some  patients  locate  it  posterior  to  the  sternum,  or  even 
between  the  shoulder-blades;  this  so-called  "heart-burn"  is  caused 
by  irritation  of  the  stomach  and  esophagus  by  excessively  acid  gastric 
contents.  If  the  burning  is  very  marked  in  the  esophagus,  we  may 
presume  that  abnormal  peristalsis  of  the  stomach  and  insufficiency 
of  the  cardia  are  cooperative  in  bringing  about  the  pyrosis. 

The  Condition  of  the  Appetite. — In  our  experience  the  appetite  is 
either  normal  or  increased  in  the  majority  of  cases.  The  instances 
where  the  appetite  is  positively  lost  are  very  rare.  Before  accepting 
a  state  of  anorexia  it  is  necessary  to  distinguish  whether  food  is 
refused  because  the  patients  have  no  feeling  of  hunger,  or  whether 
they  will  not  eat  because  they  dread  the  pain  caused  thereby.  Thirst 
is  usually  increased,  and  the  tongue  is  clean. 

Vomiting. — The  irritation  and  the  hyperacidity  set  up  by  the 
presence  of  the  ulcer  cause  increased  peristalsis  and  antiperistalsis. 
The  peristaltic  unrest  is  accompanied  by  a  feeling  of  boring  undula- 
tion in  the  epigastrium.  It  may  involve  the  intestine,  causing 
gurgling,  rumbling  noises.  The  rapid  evacuation  of  the  stomach, 
caused  by  the  intensified  peristalsis,  is  rather  favorable  to  recovery, 
because  it  brings  on  a  speedy  return  of  the  contracted  state  which 
favors  approximation  of  the  edges  of  the  ulcer  and  healing.  When 
the  pylorus  is  tightly  closed  by  spasmodic  contraction,  the  food  masses 
remain  much  longer  in  the  stomach,  and  the  mucosa  is  excessively 
irritated  by  the  intensely  acid  contents.  The  stomach  is  then  dis- 
tended by  the  constant  afflux  of  gastric  juice  and  saliva ;  also  by  the 
aspiration  of  air,  which  occurs  frequently  in  these  conditions.  The 
distention  causes  a  drawing  apart  of  the  edges  of  the  ulcer,  pain,  anti- 
peristaltic movements,  and  eventually  vomiting.  Pylorospasm  is  a 
very  grave  accompaniment,  since  it  gives  rise  to  gastric  hemorrhages 


500  ULCER   OF-   THE    STOMACH. 

and  new  erosions  by  the  development  of  the  conditions  just  described. 
The  vomited  matter  generally  shows  a  good  digestion  of  proteids  and 
imperfect  digestion  of  carbohydrates. 

Hematemesis. — This  is  probably  the  most  characteristic  sign  of 
ulcer.  It  only  occurs  in  about  half  the  cases.  Jaworski  and  Kor- 
czynski  {loc.  cit.)  assert  that  the  acidity  is  very  much  increased  imme- 
diately before  and  after  the  hematemesis.  This,  of  course,  would 
explain  the  digestion  of  the  blood  and  the  conversion  of  oxyhemo- 
globin into  hematin  hydrochlorate.  The  amount  of  the  vomited 
blood  does  not  give  a  correct  impression  of  the  degree  of  the  hemor- 
rhage, because  considerable  quantities  of  the  blood  escaping  into  the 
stomach  reach  the  intestine  and  are  passed  out  in  form  of  tarry  stools. 
The  intestinal  evacuations  may  contain  blood  several  days  after  the 
hematemesis. 

The  production  of  gastric  hemorrhage  is  favored  by  bodily  move- 
ment, but  it  may  occur  during  rest,  even  during  sleep.  When  very 
small  quantities  of  blood  escape  into  the  stomach,  they  mix  with  the 
contents,  are  partially  digested,  and  eventually  come  up  in  the  form 
of  coffee-ground  material.  When  larger  vessels  are  corroded  by  the 
ulcer,  we  have  copious  hemorrhages  of  dark-red,  pure  blood.  A  pro- 
fuse hemorrhage,  therefore,  as  a  rule;  points  to  a  deep  ulcer.  Gastric 
hemorrhages  are  accompanied  by  the  systemic  phenomena  of  inter- 
nal hemorrhages  in  any  other  part  of  the  body,  such  as  sinking  of 
arterial  pressure,  marked  pallor,  sensations  of  warmth  and  pain  in 
the  stomach,  cardiac  oppression,  nausea,  cold  sweat,  fainting,  and 
collapse.  Death  has  been  known  to  occur  in  the  state  of  collapse 
before  any  blood  was  vomited,  the  stomach  containing  at  the  autopsy 
enormous  quantities  of  liquid  and  coagulated  blood.  In  one  case  a 
solid  blood-clot  filled  the  entire  stomach.  Bodily  exertions,  the 
external  application  of  force  of  any  kind  to  the  region  of  the  stomach, 
and  straining  at  stool  have  repeatedly  been  reported  as  the  direct 
causes  of  gastric  hemorrhage.  In  patients  with  persistent  pain  in  the 
stomach,  and  dark-colored  stools,  the  latter  should  be  examined  for 
blood-coloring  matters  by  testing  for  the  hemin  crystals.  Iron, 
bismuth,  tannic  acid,  tea,  claret,  and  huckleberries  may  produce  a 
black  color  of  the  stools,  and  must  be  excluded  in  the  diagnosis. 

The  Relation  of  Hyperacidity  and  Peptic  Ulcer. — Hyperacidity  (as  an 
etiological  factor). — In  the  second  volume  of  Reynolds'  "System  of 
Medicine,"  page  930,  W.  Fox  expresses  the  opinion  that  the  cause  of 
chronicity  of  ulcer  may  be  "an  excessive  acidity  or  secretion  of  the 


RELATION    OF    HYPERACIDITY   AND    PEPTIC    ULCER.  50I 

gastric  juice,  particularly  when  the  stomach  was  empty."  But  to 
Riegel  belongs  the  credit  of  having  placed  this  condition  of  hyper- 
acidity with  gastric  ulcer  upon  a  scientific  basis.  His  results  were 
confirmed  by  von  den  Velden,  Jaworski,  Korcynski,  Ewald,  and  Boas. 

According  to  my  experience,  hyperacidity  is  present  in  90  per  cent, 
of  undoubted  gastric  ulcers.  Riegel  at  first  asserted  that  it  was  a  con- 
stant accompaniment  (F.  Riegel,  "Beitrage  zur  Diagnostik  d.  Magen- 
krankheiten,"  "Zeitschr.  f.  klin.  Med.,"  Bd.  xii,  S.  434).  But  Ger- 
hardt,  Rosenheim,  Ritter,  von  Mehring,  Cahn,  and  Hirsch  published 
cases  of  gastric  ulcer  with  normal  and  even  subnormal  acidities. 

We  have  thoroughly  tested  the  method  of  analysis  of  Cahn  and 
V.  Mehring,  and  assured  ourselves  that  it  gives  values  that  are  too  low 
for  the  free  HCl,  which  may  explain,  in  part,  some  of  the  results  and 
discrepancies  of  Rosenheim  and  the  originators  of  the  method.  We 
do  not  deny  that  there  are  undoubted  cases  of  gastric  ulcer  in  which 
there  is  a  subnormal  amount  of  HCl,  but  they  are  exceedingly  rare. 
(This  may  come  about  as  a  result  of  exhaustion  of  the  gland-cells 
consequent  upon  continued  supersecretion.  Seep.  335.)  Whenever 
the  glandular  layer  is  intact,  it  is  reasonable  to  expect  hyperacidity, 
because  the  presence  of  an  ulcer  is  a  never-ceasing  irritation. 

Riegel  has  argued  that  the  hyperacidity  is  a  primary  causative 
disturbance  and  the  ulcer  a  secondary  result  of  this,  but  Ewald's 
opinion  is  that  the  reverse  may  be  possible,  and  that  in  individuals 
with  great  irritability  of  the  secretory  nerves  an  injury  to  the  mucosa 
may  secondarily  bring  about  the  hyperacidity.  Although  this  view 
of  Ewald's  is  plausible, — and  we  do  not  wish  to  deny  the  possibility 
of  the  hyperacidity  being  a  secondar}^  result  in  exceptional  cases, — 
nevertheless  the  results  of  experiments  on  animals  are  opposed  to 
such  a  conception.  Many  injuries  to  the  mucosa,  hemorrhagic  ero- 
sions, etc.,  lead  to  recovery  and  do  not  cause  peptic  ulcer;  only  in 
individual  cases  do  ulcerations  develop. 

In  experimental  injuries  that  wdre  produced  in  the  stomachs  of 
animals  by  Cohnhein  and  Matthes  it  was  found  that  prompt  healing 
occurred ;  but  the  healing  process  was  very  much  prolonged  if  hyper- 
acidity was  artificially  caused  by  continued  addition  of  HCl  to  the  con- 
tents of  the  stomach.  On  the  other  hand,  hyperacidity  was  never 
caused  by  these  injuries  secondarily,  although  some  of  them  were 
very  extensive. 

That  a  mechanical  injun,'  to  the  stomach  can  not  of  itself  produce 
hyperacidity,  and  thus  be  converted  into  a  peptic  ulcer,  is  proved  by 


502  ULCER  OF  the;  stomach. 

the  cases  where  human  beings  swallowed  such  things  as  knives,  bits  of 
glass,  nails,  etc.,  and  still  no  ulceration  was  found  at  the  operation  or 
autopsy. 

If  this  kind  of  trauma  in  a  stomach  previously  healthy  can  not  pro- 
duce peptic  ulcer,  one  must  naturally  assume  that  a  special  predis- 
position must  previously  exist  if  such  an  ulcer  shall  develop.  It  can 
hardly  be  accepted  that  this  kind  of  a  disposition  should  develop  at 
the  moment  an  injury  is  received.  I  have  personally  observed  the 
continuance  of  the  hyperacidity  after  the  ulcer  was  healed,  and  I 
agree  with  Riegel  in  the  opinion  that  the  hyperacidity  is  the  primary 
disturbance,  and  its  continuance  explains  the  frequent  returns  of 
peptic  ulcers  after  supposed  cures  had  been  effected. 

In  stomachs  that  show  hyperchlorhydria  the  normal  digestive 
stimulation  of  food  is  followed  by  an  excessive  production  of  HCl.  If 
an  individual  afflicted  in  this  manner  receives  an  injury  to  the  gastric 
mucosa  leading  to  an  erosion,  this  will  not  heal  as  it  would  in  a  healthy 
person,  for  the  hyperchlorhydria  that  occurs  every  time  food  is  taken 
into  the  stomach  will  prevent  the  healing ;  more  than  that,  it  will  in 
itself  be  a  factor  for  further  destruction  in  the  injured  area.  Nau- 
werck  and  D.  Gerhardt  have  recently  demonstrated  the  transition  of 
hemorrhagic  erosions  into  ulcerations.  Any  necrosis  in  the  mucosa 
may  lead  to  an  ulcer.  A  slight  hemorrhagic  infiltration  may  be  the 
first  step  in  the  process,  and  later  the  infiltrated  area  becomes  ne- 
crosed. Then  the  necrotic  tissue  is  dissolved  under  the  influence  of 
the  hyperchlorhydria.  Two  factors,  then,  are  essential — ^hemorrhagic 
infiltration  and  a  very  active  hyperacid  gastric  juice. 

Nauwerck  has  pointed  out  that  erosions  may  also  be  a  secondary 
result  caused  by  mycotic  and  bacterial  necroses  of  the  mucosa. 

Inasmuch  as  the  ulcer  is  not  the  cause  of  the  hyperacidit}'^,  but 
rather  the  result,  one  can  not  be  surprised  to  find  occasionally  that 
ulcer  cases  are  not  accompanied  by  hyperacidity.  These  are  the 
exceptions.  As  a  rule,  it  can  be  stated  that  gastric  ulcer  is  associated 
with  hyperacidity. 

The  state  of  the  bowels  is  mostly  that  of  persistent  constipation; 
sometimes  the  evacuations  are  normal;  this  is  generally  the  case 
when  much  water  has  been  ingested  to  quench  the  intense  thirst. 
The  small  quantity  of  the  evacuations  is  explained  by  the  fact  that 
very  little  food  is  ingested,  and  this  is  so  thoroughly  dissolved  in  its 
proteid  constituents  by  the  very  active  gastric  juice  that  little  work 
remains  for  the  intestine.     Oftfen  the  pylorospasm,  the  cicatricial 


RELATION    OI^    HYPERACIDITY   AND    PEPTIC    ULCER.  503 

contraction  of  the  pylorus,  and  the  frequent  vomiting  are  agents  in 
producing  constipation,  because  they  prevent  the  transit  of  the  food 
into  the  duodenum.  CoUtis  and  membranous  dysentery  may  coexist 
with  gastric  ulcer  in  rare  instances. 

The  urine  is  very  much  diminished  in  quantity,  and  is  frequently 
highly  acid  when  no  emesis  has  occurred;  but  when  there  has  been 
much  vomiting,  or  when  the  stomach  has  been  washed  out  frequently, 
the  urine  may  become  alkaline.  Maly  and  Quincke  have  observed 
that  the  excretion  of  the  alkaline  constituents  of  the  blood  goes  hand- 
in-hand  with  the  increased  acid  secretion  of  the  stomach ;  at  the  same 
time  the  total  chlorids  of  the  urine  are  very  much  reduced.  The 
results  of  Charles  E.  Simon  {loc.  cit.)  indicate  that  exact  analyses  of 
the  urine  respecting  its  alkalinity,  the  subnormal  amount  of  chlorids, 
and  the  excess  of  indican,  etc.,  may  eventually  instruct  us  concerning 
the  secretory  processes  in  the  stomach,  where  it  is  impossible  to  ob- 
tain the  gastric  contents  for  examination.  (For  detailed  information 
see  chapter  on  The  Urine  in  Gastric  Diseases.) 

The  development  of  tumor  or  palpable  swelling  is  a  very  rare  occur- 
rence in  gastric  ulcer  cases.  Very  old  ulcers  may  show  considerable 
thickenings  at  the  edges,  which  at  times  become  palpable.  Gerhardt 
has  described  the  following  varieties  of  palpable  gastric  ulcer  indura- 
tions or  tumors :  ( i )  The  ulcer  itself,  with  its  hard  base  and  indurated 
edges,  is  palpable.  This  can  only  be  felt  if  it  is  located  in  that  small 
area  of  the  anterior  gastric  wall  that  can  be  palpated.  Gerhardt 
stated- that  in  some  cases  the  induration  could  be  felt  through  the  left 
lobe  of  the  liver.  I  have  never  observed  a  case  of  indurated  peptic 
ulcer,  either  clinically  or  at  autopsy,  at  which  such  palpation  was 
possible.  The  existence  of  gastric  tumor,  as  a  rule,  speaks  against 
ulcer  and  for  carcinoma ;  but  in  painful  gastric  affections  of  over  two 
years'  standing  the  existence  of  a  small  narrow  tumor  speaks  for  ulcer. 
(2)  In  cases  of  hyperacidity  and  gastralgia  a  functional  hypertrophy 
of  the  pyloric  musculature  may  develop  and  become  palpable;  this 
occurs  most  frequently  when  the  ulcer  is  located  at  the  pylorus.  This 
type  is  only  palpable  if  the  stomach  is  dilated  or  prolapsed.  If  the 
pylorus  is  in  its  normal  position,  it  can  not,  in  my  experience,  be  pal- 
pated. (3)  After  a  gastric  ulcer  has  perforated,  a  tumor  mass  may 
develop  on  the  outside  of  the  stomach  by  an  exudate,  or  an  encapsu- 
lated abscess  may  form.  In  these  extremely  rare  cases  a  rapidly 
developing  tumor  mass  develops  after  a  long-standing  gastric  disease, 
and  is  very  likely  to  be  mistaken  for  a  carcinoma.     (4)  Old  large 


504  ULCER   Olf   THE   STOMACH. 

peptic  ulcers  frequently  envelop  neighboring  organs  with  their  broad- 
ened bases.  It  is  claimed  that  pancreas,  spleen,  and  left  lobe  of  the 
liver  may  project  into  the  ulcer,  the  projecting  part  becoming  chroni- 
cally inflamed,  hard  to  palpation,  quite  massive,  and  even  capable  of 
growth.  The  demonstration  of  excess  of  HCl  in  the  stomach  contents 
will  prevent  the  diagnosis  of  cancer  in  these  cases. 

In  sixteen  cases  of  tumor  in  connection  with  gastric  ulcer,  reported 
by  Reinhard,  six  were,  at  autopsy,  found  to  be  due  to  cicatricial 
stenosis  of  the  pylorus,  six  to  adhesions  of  the  stomach  with  adjacent 
organs,  one  to  an  encapsulated  abscess,  and  three  to  foreign  bodies 
(hair,  vegetable  debris,  lime,  etc.). 

Diagnostic  Pain  Points. — Of  these,  there  are  two  that  are  of  im- 
portance: (a)  the  epigastric;  (6)  the  dorsal.  The  epigastric  pain 
point  is  in  the  median  line,  or  slightly  to  the  left,  very  rarely  to  the 
right  of  it.  It  can  not  be  correctly  called  a  point,  because  the  pain  is 
more  or  less  diffuse,  at  times  spreading  over  an  area  as  large  as  the 
palm  of  the  hand.  The  exact  limitation  of  the  epigastric  painful 
area  varies  with  the  location  of  the  stomach.  In  most  cases  it  is  close 
to  the  xiphoid  cartilage,  but  it  may  be  several  centimeters  below  that 
in  cases  of  descent  of  the  stomach,  gastroptosis,  dilatation,  etc.  The 
pain  area  described  by  Head  ("Brain,"  1896)  as  a  reflected  pain  in 
gastric  disease  is  localized  by  him  as  a  small  triangular  spot  in  the 
left  epigastrium.  The  pain  in  Head's  epigastric  triangle  is  elicited  on 
the  slightest  touch,  and  is  not  discovered  if  pressure  is  used,  such  as  is 
necessary  to  localize  the  pain  spots  of  ulcer. 

The  epigastric  pain,  which  is  very  sharply  circumscribed  and  intense, 
may  be  associated  with  a  sensation  of  throbbing  and  pulsation.  The 
dorsal  pain  region,  which  was  first  described  by  Cruveilhier,  is  also 
sharply  circumscribed.  It  was  found  in  about  one-third  of  our  cases 
at  a  level  with  the  tenth  to  the  twelfth  thoracic  vertebra.  Its  lateral 
extent  amounts  to  from  two  to  three  cm.  and  its  vertical  extent  from 
two  to  five  cm.  In  very  rare  instances  there  is  a  painful  zone  corre- 
sponding to  the  fourth  or  fifth  thoracic  vertebra.  Usually,  the  dorsal 
pain  point  is  only  present  on  the  left  side,  and  Boas  mentions  a  case  in 
which  the  dorsal  pain  was  present  and  no  epigastric  pain  complained 
of.  The  only  gastric  sensation  this  patient  had  was  a  feeling  of  pres- 
sure after  the  ingestion  of  food.  There  was  no  vomiting  and  no  blood 
in  the  stools.  Pressure  on  the  epigastric  region  did  not  cause  pain, 
but  there  was  an  intensely  painful  spot  at  the  level  of  the  twelfth 
dorsal  vertebra.     The  patient  later  on  suffered  from  severe  hema- 


CLINICAIv  FORMS   OF   GASTRIC   UIvCER.  505 

temesis.  The  localization  of  pain  is,  in  our  experience,  only  excep- 
tionally of  diagnostic  aid.  The  so-called  pain  points  are  frequently 
absent,  or,  if  present,  they  are  not  in  the  places  designated  by  Boas. 
Neurasthenic  patients  often  have  pain  points  in  these  locations  with- 
out any  other  evidence  of  ulcer. 

Clinical  Forms  of  Gastric  Ulcer. — i.  Hemorrhagic  Form. — This 
type  may  be  acute  or  chronic.  In  the  acute  type  there  are,  as  a  rule, 
no  well-marked  symptoms  of  gastric  ulcer,  which  runs  a  latent  course, 
until  suddenly  a  severe  gastric  hemorrhage  makes  the  diagnosis  clear. 
The  patient  may  die  as  a  result  of  a  profuse  loss  of  blood.  If  the 
hemorrhage  does  not  result  in  death,  an  intense  anemia  remains.  In 
the  chronic  type  the  loss  of  blood  is  not  so  considerable,  but  the 
hemorrhages  occur  more  frequently.  I  have  personally  observed  a 
case  in  which  twelve  hemorrhages  occurred  in  one  year,  and  the  stool 
contained  blood  at  all  times  during  that  year.  Such  cases  become 
extremely  cachectic,  and  pernicious  anemia  has  been  known  to  result. 

2.  The  Gastralgic  Form. — This  type  is  frequently  confounded  with 
purely  nervous  gastralgia  and  the  attacks  of  pain  occurring  in  chole- 
lithiasis. 

3.  Acute  Perforating  Type. — The  ulcerative  process  runs  a  latent 
course,  showing  only  slight  dyspeptic  symptoms.  The  acute  per- 
foration in  most  cases  occurs  suddenly  and  generally  ends  fatally. 

4.  Chronic  Dyspeptic  Form. — This  type  gives  the  impression  of 
chronic  gastritis  or  nervous  dyspepsia;  symptoms  of  gastric  ulcer 
are  wanting.  The  epigastric  region  may  be  sensitive  to  pressure, 
and  there  may  be  vomiting  and  pain  occurring  occasionally  after 
eating,  but  they  are  not  the  characteristic  sharp  pains  peculiar  to 
typical  ulcer;  they  partake  more  of  the  discomfort  shown  in  other 
chronic  diseases  of  the  stomach.  If  such  cases  show  excess  of  HCl  in 
the  gastric  contents,  and  no  abundance  of  mucus,  the  diagnosis  will 
most  probably  be  ulcer. 

5.  The  Cachectic  Form. — These  very  emaciated  and  cachectic  pa- 
tients frequently  give  the  impression  of  being  afflicted  with  a  cancer. 
The  condition  is  most  frequently  seen  in  advanced  stages  of  long- 
existing  ulcers,  in  dilatations  caused  by  cicatrices,  or  in  chronic  cases 
of  hypersecretion.  Attacks  of  pain  and  vomiting  are  still  present, 
but  the-  general  appearance  is  that  of  cachexia  and  even  maras- 
mus. 

6.  Vomitive  Form. — Here  the  emesis  is  the  most  annoying  symp- 
tom, which  is  so  persistent  that  the  sufferers  rapidly  assume  an  ad- 

l 


5o6  ULCER    OP   THE    STOMACH. 

vanced  stage  of  emaciation.  These  types  of  gastric  ulcers  are  suffi- 
cient to  demonstrate  how  variable  the  clinical  picture  may  be. 

The  Duration. — It  is  impossible  to  determine  how  long  a  gastric 
ulcer  has  existed,  and  it  is  difficult  to  determine  when  a  complete 
cure  has  been  effected.  Even  the  cessation  of  pain  is  no  proof  of  per- 
fect healing.  Large  gastric  ulcers,  with  extensive  lateral  and  vertical 
destruction,  probably  never  heal  perfectly.  As  a  rule,  the  disease 
runs  a  chronic  course.  There  are  cases  that  run  an  acute  course  and 
become  perfectly  healed  within  a  period  of  from  four  to  six  weeks. 
The  long  duration  of  the  majority  of  cases  is  largely  explained  by  the 
irritating  character  of  the  food  and  by  the  late  recognition  of  the 
character  of  the  trouble.  Complications  may  greatly  prolong  the 
disease. 

The  course  is  a  very  variable  one,  and  a  complete  cure  should  not 
be  spoken  of  until  the  patient  has  been  perfectly  free  from  all  gastric 
distress  for  six  months.  In  some  cases  the  symptoms  may  disap- 
pear very  rapidly  under  strict  diet  and  appropriate  treatment. 
After  a  few  weeks,  months,  or  years  the  same  symptoms  return. 

The  question  now  arises  whether  this  has  been  caused  by  a  new 
ulcer  or  whether  the  old  ulcer  has  not  yet  healed.  It  is  almost 
impossible  to  decide  this  point,  though  it  is  probable  that  the  old  ulcer 
has  not  yet  been  perfectly  cured.  This  is  particularly  the  case  if  the 
distress  has  only  been  relieved  as  long  as  the  patient  strictly  keeps 
to  a  careful  diet.     If  the  pains  recur  whenever  an  ordinary  diet  is 

DESCRIPTION    OF    PLATE    IX.— ULCUS    CARCINOMATOSUM     OF    THE 

PYLORUS. 

Fig.   I. — A  Section  Through  the  Wallop  the  Stomach,  Showing  the  Edge 
AND  A  Portion  of  the  Base  of  the  Ulcer. 

Objective,  two-thirds;  eyepiece,  two  inches.  Stained  with  hematoxylin  and  eosin. 
The  drawing  is  built  up  from  a  series  of  microscopic  fields.  X  about  15  dia- 
meters. 

d.  Mucous  membrane,  ra.  Muscularis  mucosae,  s.  Submucosa.  a.  Base  of  the 
ulcer,  mm.  Muscle-coat  of  stomach,  mc.  Groups  of  cancer  cells  between  the  bundles 
of  muscle-fibers,  dc.  Groups  of  cancer  cells  in  the  edge  of  the  ulcer  in  the  mucous 
membrane,  sc.  Groups  of  cancer  cells  in  the  submucosee.  a.  Necrotic  membrane 
lining  the  base  of  the  ulcer. 

Fig.  2. — A  Small  Nodule  from  the  Serous  Coat  of  the  Stomach  Over  the 

Base  of  the  Ulcer. 

Objective,    two-thirds;    eyepiece,    two    inches.      Stained    with    hematoxylin    and   eosin. 

X  about  15  diameters. 
This  figure  gives  a  good  idea  of  one  of  the  nodules  in  the  serosa.     It  is  composed 
entirely   of  a   collection    of  groups   and   masses   of    cancer   cells,    so   closely   packed 
that  the  outlines  of  the  individual  cells  can  not  be  made  out.     Except  for  these  nodular 
thickenings,  the  serosa  was  not  altered,     pc.    Cancer  masses  in  peritoneal  coat. 


PLATE  IX. 


\  ocro 


^ 


DIAGNOSIS.  507 

taken,  the  case  is  not  cured.  The  hyperacidity  may  continue  after 
the  ulcer  has  been  cured,  but  need  not  necessarily  cause  a  relapse. 

Diagnosis. — If  the  symptoms  of  pain  in  the  stomach,  gastric 
hemorrhages,  and  hyperchlorhydria  are  present  simultaneously, 
the  diagnosis  is  assured ;  but  in  the  majority  of  cases  pain  is  the  only 
symptom.  If  the  pain  occurs  only  at  the  height  of  digestion  and  at  a 
circumscribed  area  in  the  epigastrium,  and  if  the  dorsal  pain  point  is 
present,  gastric  ulcer  should  be  suspected.  Hyperchlorhydria, 
in  connection  with  continued  pain,  should  also  suggest  ulcer.  The 
pain  or  cardialgia  of  hyperchlorhydria  is  sometimes  indistinguishable 
from  that  of  gastric  ulcer.  Both  kinds  of  pain  are  caused  by  the 
digestive  irritation  of  the  food.  Both  cease  when  the  ingesta  have 
left  the  stomach.  The  only  important  point  of  difference  between 
these  tw^o  pains  is  their  regularity  with  ulcer  and  their  irregularity  in 
hyperchlorhydria.  In  the  latter  there  may  be  days  in  which  the 
patients  are  entirely  free  from  pain.  In  doubtful  cases  it  is  always 
safe,  according  to  Leube's  plan,  to  institute  treatment  for  ulcer. 

Wherever  a  chronic  morbid  process  can  be  determined  upon  with 
accuracy  and  the  characteristic  pain  points  are  present  at  the  same 
time,  the  diagnosis,  according  to  Boas,  should  be  certain  {loc.  cit.,  p. 
41).  He  attributes  less  importance  to  analysis  of  the  gastric  contents. 
There  are,  however,  atypical  forms  which  present  some  difficulty  in 
diagnosis.  Thus  there  are  cases  rarely  observed  in  which  the  patients 
never  complain  of  pain,  nor  has  the  food  any  distressing  effect  upon 
the  stomach.  In  other  cases,  although  pain  is  present,  it  is  not  aggra- 
vated by  taking  food.  In  some  well-diagnosticated  cases  food  of  all 
kinds  was  well  borne.  In  all  of  these  well-authenticated  forms  the 
diagnosis  was  assured  by  characteristic  unmistakable  symptoms, 
such  as  hematemesis  and  bloody  stools,  coming  on  afterward.  Con- 
cerning hematemesis,  it  should  be  said  that  the  differentiation  of  pul- 
monary from  gastric  hemorrhage  may  become  necessary.  This  may 
be  facilitated  by  a  study  of  the  subjoined  scheme: 

HEMORRHAGES  FROM  THE 
Lung.  Stomach. 

1.  Blood  is  bright  red,  foamy.  i.   Blood  is  dark  brown,  partly  coagulated, 

frequently  mixed  with  food,  sometimes 
acid. 

2.  Physical  signs  point  to  a  pulmonary  or  2.  Physical  examination  evinces  a  gastric 
cardiac  affection — the  stomach  may  be  or  hepatic  affection,  or  stasis  in  portal 
affected  secondarily.  circulation. 

3.  Pulmonary  hemorrhages  followed  by  3.  Gastric  hemorrhages  are  frequently  as- 
rusty-colored    sputa    for    days     (gener-  sociated  with  tar-colored  stools. 

ally),  but  there  is  no  blood  in  the  stools. 

4.  Physical  signs  of  pulmonary  or  cardiac  4.  Physical  examination  of  heart  and  lungs 
disease — moist  riles.  usually  negative. 


508  UIvCER   OF   THE    STOMACH. 

The  diagnosis  becomes  complete  if  the  characteristic  pain  points 
are  present,  with  prompt  aggravation  of  pain  soon  after  taking  food, 
vomiting  showing  hyperacidity,  hematemesis,  and  a  history  of  chronic 
trouble. 

The  blood  coming  from  the  stomach  does  not  necessarily  originate 
from  an  ulcer.  One  may,  in  rare  instances,  be  called  upon  to  exclude 
carcinoma,  portal  vein  stasis  producing  passive  congestion,  gastric 
varicosities,  toxic  corrosions,  traumatisms,  scurvy,  acute  yellow 
atrophy  of  the  liver,  and  yellow  fever.  The  hemorrhages  of  carci- 
noma are  small  in  quantity  compared  to  those  of  ulcer,  and  in  cancer 
the  blood  is  more  frequently  decomposed  and  of  a  coffee-  or  chocolate- 
brown  color,  and  there  are  rarely  any  bloody  stools.  Charcot  has 
reported  hematemesis  in  hysteria  (crises  gastriques),  but  Debove 
suggests  {loc.  cit.)  that  organic  and  functional  nervous  diseases  may 
be  coincident  with  ulcer.  In  sudden  gastric  hemorrhages  the  pre- 
vious history  will,  as  a  rule,  enable  one  to  distinguish  between  the 
above-mentioned  possibilities.  In  hemorrhage  from  passive  conges- 
tion due  to  stasis  of  the  portal  vein  the  epigastric  pain  is  very  slight 
or  entirely  absent. 

Affections  of  the  transverse  colon — some  forrns  of  colitis  (mem- 
branous and  simple  catarrhal  types), — as  well  as  severe  colic,  copro- 
stasis,  and  prolapse  of  the  colon,  may  closely  mimic  the  clinical  pic- 
ture of  gastric  ulcer.  The  pain  area  of  the  transverse  colon  can  not, 
in  my  experience,  be  definitely  separated  from  that  of  the  stomach 
by  palpation.  In  this  connection  I  would  emphasize  that  pains  of 
the  colon  cease  and  frequently  disappear  entirely  after  this  part  of 
the  intestines  is  thoroughly  evacuated.  In  the  greater  proportion  of 
these  diseases  of  the  colon  the  amount  of  free  HCl  in  the  stomach  is 
markedly  reduced,  or  occasionally  may  be  absent  entirely.  In  ulcer 
there  is  hyperacidity,  as  a  rule.  Careful  inspection  and  examination 
of  the  stool  is  necessary  in  both  diseases,  and  will  often  instruct  us 
regarding  the  condition  of  the  colon. 

Whether  colitis  may  lead  up  to  functional  disturbances  of  the  stom- 
ach, as  Kleiner  asserts,  is  still  uncertain. 

Cholelithiasis  may  be  confounded  with  ulcer  when  there  has  been 
no  blood  in  the  vomit  or  stools,  nor  any  grit,  sand,  or  stones  in  the 
evacuations.  The  following  signs  and  symptoms  are  then  of  value : 
The  pain  in  hepatic  colic  is  not  in  connection  with  the  taking  in  of 
food;  it  draws  from  the  median  line  to  the  right.  The  dorsal  pain 
point  of  ulcer,  if  present,  is  located  at  the  level  of  the  twelfth  thoracic 


CHOLELITHIASIS.  509 

vertebra,  to  the  left  and  very  close  to  the  body  of  the  twelfth  verte- 
bra. But  the  dorsal  pain  point  of  cholelithiasis,  if  present,  is  located 
to  the  right,  about  two  or  three  fingers'  breadths  from  the  twelfth 
dorsal  or  first  lumbar  vertebra.  In  ulcer  there  is  rarely  any  pain  on 
the  right  side ;  even  if  there  is,  it  is  much  less  intense,  and  in  chole- 
lithiasis there  is  rarely  any  pain  to  the  left  of  the  spinal  column. 

In  cholelithiasis  the  right  lobe  of  the  liver  and  the  gall-bladder  are 
enlarged  after  an  attack;  and  during  the  intervals  between  the 
attacks  all  kinds  of  foods  can  be  eaten  with  impunity.  In  chole- 
lithiasis the  amount  of  HCl  in  the  gastric  contents  is  normal  or  sub- 
normal, or  the  contents  may  not  show  any  free  HCl ;  in  ulcer  there  is 
hyperacidity.  Icterus,  when  repeatedly  observed,  following  attacks 
of  pain,  strengthens  the  diagnosis  of  cholelithiasis,  but  it  must  be 
emphasized  that  with  duodenal  ulcer  icterus  is  occasionally  observed. 
In  private  practice  I  have  observed  two  cases  in  which  cholelithiasis 
and  gastric  ulcer  occurred  contemporaneously. 

Diagnosis  of  the  Complications  and  Consequences  of  Gastric  Ulcer. — 
These  are:  (i)  The  perforation  peritonitis;  (2)  cicatricial  stenosis 
of  the  pylorus;  (3)  the  transition  of  ulcer  into  carcinoma,  or  ulcus 
carcinomatosum ;  (4)  hour-glass  stomach  from  cicatricial  contrac- 
tions; (5)  subphrenic  abscess;  (6)  progressive  pernicious  anemia. 

The  diagnostic  signs  of  perforative  peritonitis  are:  (a)  great 
rigidity  of  the  abdominal  muscles,  flat  abdomen;  (b)  disa.ppearance 
or  diminution  of  liver  dullness ;  this  sign  may  be  absent,  however,  if 
only  liquid  gastric  contents  and  no  air  escape  into  the  peritoneum; 
(c)  vomiting.* 

Carcinomatous  Degeneration  of  Peptic  Ulcer  (Ulcus  Carcinomato- 
sum).— It  is  logical  to  assume  that  peptic  ulcers,  if  they  are  to  become 
carcinomatous  at  all,  are  most  likely  to  become  so  in  those  regions  of 
the  stomach  where  they  are  subjected  to  the  greatest  irritation. 
Thus  we  find  that  in  45  cases  of  carcinomatous  ulcers  of  the  stomach 
in  which  the  location  is  stated  37  were  in  the  pyloric  part,  9  in  the 
lesser  curvature,  i  in  the  greater  curvature,  and  i  about  the  middle 


*The  diagnosis  of  perforation  has  been  attempted,  when  other  signs  failed,  by  punc- 
turing through  the  abdominal  walls  with  a  sterilized  hypodermic  needle,  when  the 
gaseous,  bacterial,  and  cellular  evidences  of  perforation  can  at  times  be  aspirated.  (Test 
for  li.^S  by  lead-acetate  paper ;  when  the  abdomen  is  v.ery  tympanitic,  this  sign  is  almost 
pathognomonic.)  The  puncture  is  made  when  the  patient  is  in  the  dorsal  position.  The 
escaped  gases  will  rise  upward  between  the  intestines  and  the  peritoneal  wall.  There  is 
danger  of  puncturing  the  intestines  in  this  method. 


5IO  ULCER   OF  THE   STOMACH. 

of  the  stomach  (this  was  a  case  of  hour-glass  stomach) .  Fiitterer  has 
pointed  out  that  the  edges  of  a  peptic  ulcer  do  not  become  carcinoma- 
tous all  over  at  once,  but  that  those  parts  degenerate  first  which  are 
subjected  to  the  greatest  mechanical  insults. 

In  the  pyloric  region  the  lower  edges  of  the  ulcer,  those  which  are 
turned  toward  the  pylorus,  are,  as  a  rule,  the  seat  of  the  first  cancer 
formation.  In  cases  where  the  location  of  the  stomach  was  distorted 
by  adhesions  it  was  the  inferior  portion  of  the  peptic  ulcer  which 
degenerated  first.  This  degeneration  of  an  ulcer  preferably  at  its 
inferior  portion  gives  to  a  section  of  the  ulcer  when  made  perpendicu- 
lar to  its  surface  the  appearance  of  a  fish  hook  (see  plate  ix, 
opposite  p.  506).  Fiitterer  ("Ueber  die  Aetiologie  des  Car- 
cinoms,"  p.  iii)  makes  the  assertion  that  the  majority  of  cancers 
of  the  stomach  originate  from  gastric  ulcers,  which,  in  his  opinion, 
makes  the  prognosis  of  peptic  ulcer  very  grave,  and  he  distinguishes 
between  an  early  prognosis  and  a  remote  prognosis.  The  former 
refers  to  the  healing  of  the  peptic  ulcer,  the  disappearance  of  the 
pains,  and  dyspeptic  distress.  By  the  late  prognosis  he  refers  to  the 
possibility  of  pyloric  stenosis  and  carcinomatous  degeneration.  The 
early  prognosis  is  good;  the  remote  prognosis  is  bad.  He  minutely 
describes  the  case  of  adenocarcinoma  which  had  originated  from  a 
comparatively  recent  peptic  ulcer  but  one  centimeter  in  diameter. 

From  a  very  large  experience  both  with  the  clinical  symptomatol- 
ogy of  peptic  ulcer  and  also  from  observations  gained  at  numerous 
autopsies  and  surgical  operations  upon  the  stomach  I  am  loath  to 
accept  Futterer's  statement  that  the  majority  of  carcinomas  of  the 
stomach  arise  from  gastric  ulcer.  He  tabulates  only  52  reliable 
cases  of  carcinomatous  ulcers  of  the  stomach.  In  the  vast  amount  of 
clinical  and  pathological  literature  on  this  subject  (see  literature  on 
Gastric  Ulcer)  there  would  surely  have  been  a  larger  number  of  ob- 
servations if  Futterer's  assertion  was  correct.  Clinical  experience 
shows  that  peptic  ulcers,  as  a  rule,  heal  favorably  and  permanently, 
and  remote  dangerous  results  are  the  exception.  This  does  not  mean 
that  we  should  allow  peptic  ulcer  patients  to  continue  unobserved 
after  the  so-called  cure.  If  the  diagnosis  of  a  cicatrix  of  the  pylorus 
is  certain,  a  gastro-enterostomy  should  be  urgently  advised  to  pre- 
vent the  cancer  formation  by  the  inevitable  irritation  of  the  cicatrix 
through  food.  The  diet  should  always  be  carefully  controlled: 
coarse  foods  nmst  be  avoided,  all  food  should  be  well  chewed  and 
insalivated,  and  slowly  eaten.      The  diet  should  be  the  same  as  during 


SUBPHRENIC   ABSCESS.  5II 

the  active  period  of  the  ulcer,  for  about  six  months  thereafter.  As 
early  as  1897  I  pointed  out  the  characteristic  fish-hook  form  of  car- 
cinomatous gastric  ulcer.  (See  Hemmeter  and  Ames,  "N.  Y.  Med. 
Record,"  Sept.  11,  1897,  p.  366.) 

Histologic  Characteristics  of  Carcinomatous  Ulcer  of  the  Stomach. — 
The  entire  muscularis  rises  up  in  an  oblique  direction  immediately  in 
front  of  the  edge  of  the  ulcer.  In  thus  ascending  the  true  muscularis 
becomes  merged  into  the  muscularis  mucosa,  which  is  turned  down- 
ward, and  is  much  permeated  by  connective  tissue.  As  the  true 
muscularis  curves  upward  its  fibers  are  not  extensively  suppurated, 
and  it  frequently  happens  that  the  base  of  the  ulcer  is  formed  by 
what  were  originally  the  lowermost  fibers  of  the  true  muscularis. 
When  this  condition  is  seen  and  also  the  peculiar  fish-hook  form, 
upon  which  Fiitterer  lays  so  much  stress,  we  are,  without  doubt,  con- 
fronted with  a  carcinoma  which  has  arisen  upon  the  basis  of  a  gastric 
ulcer. 

According  to  Rosenheim  ("Zeitschr.  f.  klin.  Med.,"  Bd.  xvii,  S. 
116),  about  five  to  six  per  cent,  of  gastric  ulcers  develop  carcinomata 
at  their  margins,  and  these  carcinomata  are  said  to  be  associated  with 
a  pronounced  hyperacidity. 

The  so-called  hour-glass  stomach  may  be  produced  by  one  or  more 
cicatrices  in  the  neighborhood  of  the  antrum  pylori.  Cicatrices  of 
the  duodenum  may  cause  a  dilatation  beyond  the  pylorus,  by  which 
the  latter  will  itself  constitute  the  narrowing  or  isthmus  of  what  very 
much  resembles  an  hour-glass  stomach  (Reiche,  "Jahrb.  d.  Ham- 
burger Staatskrankenanstalt,"  1890,  p.  180). 

Subphrenic  Abscess  (Pyopneumothorax  subphrenicus) . — In  1880, 
Leyden  first  described  a  combination  of  diseases  which  followed  per- 
forative peritonitis  or  escape  of  pus  from  the  intestines  into  the  peri- 
toneum. A  purulent  exudate  forms  in  the  lower  parts  of  the  right  or 
left  thoracic  cavity  under  symptoms  of  inflammation,  but  no  cough- 
ing or  expectoration  is  connected  therewith.  The  posterior  and 
lower  thoracic  regions  give  dullness  on  percussion,  absence  of  vesicu- 
lar murmur,  and  fremitus.  Metallic  sounds  can  be  made  out  when 
one  percusses  and  auscults  simultaneously.  The  succussion  sound  is 
distinct.  The  lung  is  distinctly  intact  above  these  parts.  The  re- 
spiratory murmur  is  vesicular  and  the  fremitus  is  maintained  down 
to  the  fourth  or  fifth  rib ;  from  here  on,  the  respiratory  murmur  sud- 
denly ceases.  The  dullness  that  corresponds  to  the  exudate  changes 
with  various  positions  of  the  body.  The  signs  of  equally  distributed 
34 


512  UI.CER   OF   THK    STOMACH. 

pressure  in  the  pleura  are  wanting.  The  movements  of  the  corre- 
sponding half  of  the  thorax  are  not  coordinated,  the  intercostal  spaces 
are  almost  obliterated,  and  the  herat  is  slightly  pushed  to  the  other 
side. 

If  the  exudate  is  on  the  right  side,  the  liver  projects  far  into  the 
abdomen,  and  can  be  felt  at  or  below  the  umbilicus.  The  exudate 
may  perforate  into  the  respiratory  passages  and  cause  sudden  and 
abundant  expectoration  of  foamy  pus  containing  hepatic  cells.  In 
1894  Maydl  collected  179  cases  of  subphrenic  accumulations  of  pus. 
In  twenty  per  cent,  of  these  cases  perforating  ulcers  of  the  stomach 
or  duodenum  were  found  to  be  the  causes.  ("Subphrenic  Abscess," 
Meltzer,  in  the  "New  York  Med.  Jour.,"  June  24,  1893.)  Progres- 
sive pernicious  anemia  as  a  concomitant  phenomenon  of  ulcer  can  be 
recognized  by  the  reduction  of  the  number  of  red  corpuscles  with 
relative  increase  of  percentage  of  hemoglobin  and  the  appearance  of 
the  poikilocytes,  gigantoblasts,  microcytes,  and  macrocytes.  (See 
chapter  on  The  Blood  in  Gastric  Diseases,  p.  401  et  seq.) 

Senator  suggests  that  a  left-sided  pleurisy  immediately  or  remotely 
following  gastric  ulcer  should  suggest  the  possibility  of  a  subphrenic 
abscess.  The  following  are  further  suggestive  points  in  these  cases : 
First,  violent  pains  in  the  epigastrium,  or  in  one  or  other  hypochon- 
drium.  Second,  pain  and  stiffness  in  the  back  during  efforts  to  sit 
up.  Third,  painful  eructation,  sobbing  and  singultus.  Fourth, 
reclining  posture  of  the  patient  on  his  back,  because,  as  a  rule,  with 
extensive  pleuritic  extravasations  the  patient  maintains  a  position  on 
the  diseased  side.  Fifth,  edema  of  the  lower  lateral  and  posterior 
thoracic  walls,  at  times  extending  to  the  loins. 

In  the  presence  of  extensive  pleurisy  or  empyema,  the  coexistence 
of  these  five  conditions  would  justify  the  supposition  of  a  subphrenic 
abscess. 

The  general  subcutaneous  emphysema  as  a  complication  of  perfor- 
ation of  gastric  ulcer  is  a  very  rare  occurrence,  to  which  Demarquay 
first  called  attention. 

Treatment  of  Gastric  Ulcer, — Prophylactic. — If  gastralgias  are 
frequent  in  a  person  afflicted  with  hyperacidity,  the  diet  must  be 
very  mild  and  unirritating ;  two  weeks  of  a  milk  diet  will  be  the  safest. 
Sudden  deviations  in  the  temperature  of  the  food  must  be  avoided, 
daily  evacuations  must  be  effected  by  suitable  diet,  and,  if  need  be, 
Carlsbad  salts,  and  the  hyperacidity  remedied.  The  dietetic  and 
medicinal  treatment  will  vary  according  to  the  presence  or  absence 
of  hematemesis. 


TREATMENT   OE   GASTRIC   ULCER.  513 

Treatment  of  Hematemesis  and  the  Period  Immediately  Following 
It. — During  the  stages  of  blood  vomiting  the  patient  must  remain 
absolutely  quiet  in  bed  and  not  even  arise  for  urination  or  defecation. 
Positively  nothing  should  be  permitted  by  the  mouth,  not  even  ice. 
If  the  patient  is  well  nourished  no  alimentation  by  the  rectum  is  ad- 
visable, because  this  necessarily  disturbs  the  rest  and  compels  the 
stomach  to  move  because  of  the  changes  in  position  required.  If  the 
patient  is  weak  and  anemic,  a  nourishing  enema  may  be  imperatively 
indicated  every  four  hours.  The  enema  most  favored  is  that  of  Boas, 
consisting  of  250  gm.  of  milk,  the  yolks  of  two  eggs,  a  teaspoonful  of 
salt,  one  ounce  of  good  claret  (we  favor  Beaune- Burgundy  for  this 
purpose),  and  one  tablespoonful  of  aleuronat  flour.  Previous  to 
giving  an  enema  for  nutritive  purposes,  the  rectum  and  colon  must  be 
cleaned  by  a  high  irrigation  with  one  liter  of  warm  water.  The  above 
ingredients  are  thoroughly  mixed  by  means  of  an  egg-beater,  warmed 
to  about  99°  F.,  and  permitted  to  run  in  under  gentle  pressure,  care 
being  taken  that  the  tube  is  introduced  as  far  up  into  the  sigmoid 
flexure  as  possible. 

When  the  hematemesis  is  copious  and  persistent,  a  hypodermic 
injection  of  ergotal,  20  to  30  minims,  should  be  given  at  once.  With 
this  preparation  of  ergot  we  have  had  extensive  experimental  and 
clinical  experience  (see  "Med.  News  "  for  Jan.  31,  Feb.  7,  Mar.  7  and 
14,  1 89 1,  "An  Experimental  and  Clinical  Study  of  Ergot,"  by  J.  C. 
Hemmeter).  The  use  of  ergot  for  hematemesis  has  the  indorsement 
of  Riegel  {loc.  cit.),  Ewald,  and  Nothnagel.  At  the  same  time  an 
ice-bag  is  placed  over  the  epigastrium,  and  if  the  pain  is  severe  an 
injection  of  ^  of  a  grain  of  morphin  should  not  be  delayed,  as  this 
drug  acts  as  an  adjuvant  to  the  hemostatic  by  the  ease  and  quiet  it 
brings  about.  For  three  days  following  hematemesis  this  treatment 
should  not  be  changed,  and  no  food  allowed  by  mouth.  The  treat- 
ment from  the  fourth  to  the  seventh  day  after  consists  of  absolute 
rest  in  bed,  a  wet  pack  covered  with  oiled  silk  and  bandage  being 
applied  to  the  epigastrium.  And  now  one  may  resume  feeding  by 
the  mouth,  but  in  form  of  liquids  only, — half  milk,  half  lime-water; 
or  milk  with  a  small  addition  of  coffee  or  tea,  never  more  than  luke- 
warm; also  beef-tea,  to  which  nutrose,  meat-powder,  or  somatose 
have  been  added,  and  egg-albumen  water.  Chocolate,  yolks  of  eggs, 
and  all  alcoholic  beverages  must  be  forbidden  in  this  stage. 

In  the  second  week  after  the  hemorrhage  a  typical  cure  for  ulcer, 
according  to  principles  laid  down  by  Wilson  F'ox  ("Diseases  of  the 


514  UIvCER   OF   THE    STOMACH. 

Stomach,"  1872,  p.  146),  v.  Leube  ("Ziemssen's  Handbuch,"  Bd. 
VII,  2,  p.  120),  and  V.  Ziemssen  (Volkmann's  "Sammlung  klin.  Vor- 
trage,"  No.  75),  should  be  instituted.  These  systematic  treatments 
are  in  the  main  rest-cures  combined  with  the  daily  use  of  a  glass  of 
Carlsbad  Miihlbrunnen  water,  liquid  or  semiliquid  diet,  and  hot 
applications  to  the  epigastrium.  Every  morning  the  patient  takes 
a  glass  of  (40°  R.)  warm  Miihlbrunnen  in  which  five  to  ten  gm.  of 
natural  or  artificial  Carlsbad  salts  have  been  dissolved.  Spongiopi- 
lin  cut  into  any  requisite  shape  and  dipped  into  hot  water  is  applied 
externally  to  the  epigastrium,  and  renewed  every  three  hours  night 
and  day.  The  diet  consists  mainly  of  milk  and  whipped  eggs ;  if  there 
is  great  weakness,  the  Boas  enema,  containing  perhaps  two  ounces 
of  claret,  should  be  given,  and  if  the  pulse  is  feeble,  hypodermic 
injections  of  digitalin  -jq-  of  a  grain,  and  strychnia  -^-^  of  a  grain.  In 
one  case  of  profuse  hematemesis  we  gave  an  intravenous  injection 
of  500  c.c.  of  sterilized  normal  salt  solution.  The  pulse  had  left  the 
wrist,  and  was  barely  perceptible  at  the  carotid;  the  effect  was 
prompt,  and  the  opinion  of  the  assisting  colleagues  was  that  life  was 
saved  thereby, — the  case  recovering  later  on  under  the  nitrate  of 
silver  treatment. 

In  the  third  week,  when  the  pain  in  the  epigastrium  and  general 
cardialgia  have  ceased,  the  patient  may  be  permitted  to  rest  on  the 
sofa,  and  the  Carlsbad  water  is  continued.  We  might  remark  here 
that  the  Saratoga  Carlsbad  and  the  Hathorn  spring  waters  act  quite 
as  well  as  the  imported.  In  fact,  the  only  objects  of  the  Carlsbad 
water  in  the  cures  of  Leube  and  Ziemssen  are  the  neutralization  of 
the  hyperacidity  and  the  promotion  of  intestinal  evacuation.  One 
must  not  gain  the  impression  that  Carlsbad  waters  or  salts  have  any 
direct  or  specific  curative  effect.  Ewald  (loc.  cit.,  p.  275)  declares 
that  many  a  patient  who  went  to  Carlsbad  might  have  recovered 
more  rapidly  if  he  had  taken  the  rest-cure  at  home.  To  neutralize 
the  hyperacidity  and  prevent  autodigestion  I  usually  give  the  fol- 
lowing : 

R .     Magnesiee  ustse, 
Sodii  carbonatis, 

Potassii  carbonatis,     ...  aa  ....     5.0  3J     +  S^^-  ^^ 

Sacchar.  lactis, 25.0  S^j  +  gi^s-  xx. 

SiG. — Half  a  teaspoonful  dry  on  the  toiiyue  every  three  hours. 

In  the  third  week  one  may  permit  dipped  cakes,  toast,  or  zwie- 
back; broiled  sweetbread  or  calf's  brain,  dumplings  made  of  finely 


TREATMENT   OF   GASTRIC   ULCER.  515 

divided  meat,  broiled  pike,  bluefish,  trout,  oysters,  in  very  small 
quantities.  In  the  fourth  week  purees  made  of  potatoes,  peas,  or 
beans  rubbed  through  a  sieve,  stewed  apples,  pears,  and  plums. 
Saratoga  Vichy  may  be  allowed ;  all  vegetables  that  can  be  prepared 
in  puree  (gruel)  form,  such  as  spinach,  carrots,  peas,  etc.  For  many 
years  the  patient  must  avoid  raw  fruits,  all  sour,  acid,  or  spiced 
food  and  drink,  ice-cream,  and  all  cold  and  hot  beverages.  If  there 
has  been  no  hematemesis  the  treatment  had  best  be  carried  out  along 
these  lines  also.  On  page  243  detailed  diet-lists  for  cases  of  gastric 
ulcer  are  given.  In  rebellious  cases  of  recurrent  gastralgias,  vomit- 
ing, and  hyperacidity,  McCall  Anderson  ("Brit.  Med.  Jour.,"  May  10, 
1890)  and  H.  B.  Donkin  ("The  Lancet,"  Sept.  27,  1890)  recommend 
a  total  abstinence  cure  of  two  to  three  weeks,  during  which  the 
patients  are  fed  exclusively  by  rectal  enemata  (three  to  four  in  the 
day) ;  hot  applications  to  the  epigastrium  are  also  used.  After  ten 
days  of  rectal  feeding  they  cautiously  and  slowly  return  to  feeding 
by  the  mouth  (milk,  bouillon,  egg-albumen) .  We  have  tried  this  in 
a  number  of  cases  in  which  relapses  had  occurred  after  the  rest-cure, 
and  can  speak  in  favor  of  the  method.  (See,  also,  A.  P.  Gros,  "Traite- 
ment  de  Malad.  de  I'estomac,  par  la  cure  de  Repos  absolu,"  etc.,  Paris, 
1898.)  Gerhardt  and  Boas  speak  very  favorably  of  nitrate  of  silver 
in  light  cases  of  gastric  ulcer.  The  latter  begins  with :  I^ .  Argenti 
nitratis  0.25  to  120  of  peppermint  water;  one  tablespoonful  three 
times  a  day  on  an  empty  stomach.  Then  the  dose  is  increased  to 
0.3  to  120  of  water,  of  which  two  bottles  are  taken,  and  finally 
0.4  to  120  of  water,  of  which  also  two  bottles  are  advised.  This 
is  combined  with  a  sparing  diet  and  as  much  rest  as  possible. 

Fleiner  and  Kussmaul  recommend  bismuth  subnitrate  in  all  irrita- 
tive conditions  of  the  gastric  mucosa— old  ulcers,  erosions,  excoriating 
carcinomata.  Fleiner  employs  it  in  the  following  manner:  10  to  20 
gm.  (150  to  300  grs.)  of  bismuth  subnitrate  are  stirred  in  200  c.c.  of 
warm  water;  after  the  stomach  has  been  thoroughly  cleansed  by 
lavage,  this  suspension  is  poured  into  the  stomach  and  allowed  to 
remain  three  minutes ;  then  the  clear  water  is  siphoned  out,  the  bis- 
muth remaining  behind  and  forming  a  coating  to  the  injured  places 
in  the  stomach.  It  is  a  modified  direct  or  local  treatment.  We 
usually  employ  three  drams  of  bismuth  subnitrate  and  one  dram  of 
bismuth  subgallate  in  a  pint  of  warm  water,  having  previously  thor- 
oughly cleansed  the  stomach  with  solutions  of  sodium  bicarbonate 
(i5ss  to  a  pint),  the  state  of  the  ulcer  permitting.     Recently  we  have 


5l6  ULCER   OF    THE    STOMACH. 

used  the  bismuth  salts  by  insufflating  them  into  the  stomach  in  a  dry 
form  by  a  powder  blower. 

In  chronic  cases  in  which  Kleiner's  treatment  can  be  employed  it 
relieves  pain  promptly,  reduces  the  hyperacidity,  and  promotes 
healing ;  it  is  worth  trying  in  cases  of  long  standing.  Direct  or  local 
treatment  of  this  kind  is  permissible  when  there  have  been  no  hemor- 
rhages or  tarry  stools  for  one  month.  During  this  time  the  ordinary 
cures  by  diet,  rest,  Carlsbad  Mtihlbrunnen,  etc.,  must  have  been  em- 
ployed. There  must  be  no  sensitiveness  to  pressure  on  the  epigas- 
trium. Chronic  ulcers  that  have  resisted  dietetic  and  medicinal 
treatment  have  been  successfully  treated  by  this  method  by  Matthes 
{loc.  cit.),  O.  Fischer  {loc.  cit.),  and  Stintzing  {loc.  cit.).  The  anemia 
following  ulcer  may  require  iron,  arsenic,  strychnin.  Iron  prepara- 
tions must  contain  no  acid. 

J.  Petruscky  has  reported  two  cases  of  primary  tubercular  ulcers  of 
the  stomach  which  were  apparently  cured  by  injections  of  tuberculin 
("Verhandlungen  d.  XVII  Congresses  f.  innere  Med.,"  1899,  S.  366). 

Surgical  treatment  becomes  necessary  when,  after  a  trial  of  the 
aforesaid  methods,  the  ulcer  or  ulcers  prove  very-  obstinate  and  not 
amenable  to  medical  treatment,  or-  because  hemorrhages  may  be- 
come so  abundant  and  frequent  as  to  endanger  life,  or,  lastly,  because 
of  perforation.  Nelson  C.  Dobson  ("Bristol  Medical  and  Surg. 
Jour.,"  1883)  first  advocated  surgical  interference  for  perforating 
gastric  ulcer.  In  this  country,  Robert  F.  Weir,  of  New  York,  has 
contributed  the  most  important  work  to  this  domain  of  surgery. 
His  last  important  paper  (Robert  F.  Weir  and  E.  M.  Foote,  "The 
Surgical  Treatment  of  Round  Ulcer  of  the  Stomach  and  Its  Sequelae," 
etc.,  "Medical  News,"  April  25  and  May  2,  1896)  contains  an  account 
of  78  cases  of  laparotomy  for  acute  perforation  of  gastric  ulcer.  Keen 
and  Tinker  have  added  statistics  of  78  further  cases  ("Phila.  Med. 
Jour.,"  vol.  I,  p.  1 106);  these  articles  contain  also  the  indications, 
prognosis,  etc.,  of  operations  for  gastric  ulcer. 

Gastric  ulcers  have  been  excised  entirely,  the  sequelae  thereof  have 
been  removed  by  the  severing  of  peritonitic  adhesions,  and  hour-glass 
stomach  much  improved  by  gastro-anastomosis  (see  von  Hacker, 
"Ueber  Magenoperationen  bei  Carcinom  u.  bei  narbigen  Stenosen," 
published  by  Wilh.  Braumiiller,  Wien  and  Leipzig,  1895). 

For  further  details  concerning  the  operations  on  the  stomach  for 
recent  ulcers  and  for  cicatrices,  we  refer  to  the  sections  on  Surger}^  of 
the  Stomach. 


tre:atment  of  gastric  hemorrhage;.  517 

Treatment  of  Exhaustive  Gastric  Hemorrhage  by  Transfusion  and 
Intravenous  Injection  of  Normal  Salt  Solution. — Michel  transfused 
successfully  in  a  case  of  extreme  anemia  following  gastrorrhagia 
("Berl.  klin.  Wochenschr.,"  1870,  No.  49).  In  a  case  of  profuse  and 
repeated  hematemesis,  which  followed  washing  out  the  stomach, 
Michaelis  infused  into  the  veins  350  c.c.  of  solution  of  common  salt. 
Reaction  gradually  foUowed  and  the  patient  recovered.  This  case, 
which  was  one  of  probable  ulcer,  illustrates  the  advantages  of  infus- 
ing a  small  quantity  (ibid.,  June  23,  1884).  The  sudden  infusion  of 
quantities  of  liquid  exceeding  500  c.c.  will  cause  such  an  abrupt  rise 
in  arterial  pressure  that  the  injured  blood-vessels  in  the  gastric  mucosa 
may  reopen,  causing  renewed  profuse  hemorrhages.  The  dangers 
are  illustrated  by  a  case  reported  by  von  Hacker,  who  infused  1500 
c.c.  of  salt  solution  into  a  patient  in  a  state  of  extreme  collapse  re- 
sulting from  hemorrhage  from  gastric  ulcer.  The  patient  rallied,  but 
he  died  three  hours  after  the  infusion  from  renewed  hemorrhage 
("Wiener  med.  Wochenschr.,"  1883,  No.  37).  In  Legroux's  case  of 
gastric  ulcer,  renewed  hemorrhage  and  death  followed  the  transfusion 
of  only  80  gm.  of  blood  ("Arch.  Gen  de  Med.,"  Nov.,  1880).  In  a 
case  quoted  by  Roussel,  Leroy  transfused  130  gm.  of  blood  into  a  girl 
twenty  years  old,  who  lay  at  the  point  of  death  from  repeated  hemor- 
rhages from  a  gastric  ulcer.  In  the  following  night  renewed  hemor- 
rhage and  death  occurred  ("Gaz.  des  Hop.,"  September  22,  1883). 
According  to  the  experiments  of  Schwartz  and  Ott,  the  transfusion, 
or,  rather,  infusion,  of  physiological  salt  solution  is  as  useful  as  that  of 
blood,  and  it  is  simpler  and  unattended  with  some  of  the  dangers  of 
blood  transfusion.  The  formula  is  chlorid  of  sodium,  6  parts ;  dis- 
tilled water,  1000.  Our  personal  experience  is  confirmatory  of  the 
observations  of  these  last-mentioned  experimenters. 

Fleiner  {loc.  cit.)  favors  the  excision  of  simple  gastric  ulcer,  when 
external  (social)  conditions  render  a  suitable  diet  and  treatment  im- 
possible. We  can  not  advocate  this  heroic  treatment  for  simple,  un- 
complicated ulcer,  feeling  convinced  that  the  various  treatments  with 
which  we  are  now  acquainted  are  eminently  successful.  But  if  a 
laparotomy  has  been  undertaken  and  the  stomach  has  been  opened 
for  other  indications  (suspicion  of  peritonitis,  perigastritis,  appendi- 
citis, carcinoma,  perforation),  and  an  uncomplicated  ulcer  is  dis- 
covered, the  excision  of  the  latter  is  undoubtedly  justifiable,  and 
has  been  successfully  carried  out  by  Cordua,  Kansche,  Maurer  (at 
Czerny's  clinic),  and  Mintz  {loc.  cit.).     In  the  latter  case  the  gastric 


5l8  ULCER   OE   THE   STOMACH. 

functions  were  entirely  recovered.  Extreme  and  persistent  gastric 
pain  has  been  the  indication  for  gastro-enterostomy  in  a  case  of 
Cahn's  {loc.  cit.). 

LITERATURE 

ON  ULCER   OF  THE  STOMACH, 
In  addition  to  the  text-books  mentioned  in  the  literature  on  gastritis. 

1.  Abaytia,  W.,  "  Trataimento  de  la  ulcera  heptica  en  plena  actividad 
gastrica  mitigado  por  la  alimentacion  rectal,"  "  Rev.  de  med.  y  cirug.  pract.," 
Madrid,  1898,  XLiii,  401,  489,  529. 

2.  Adamson,  R.  O.,  "  The  Symptoms  of  Perforated  Gastric  Ulcer,  with  Two 
Recent  Cases,"  "  Scot.  M.  and  S.  J.,"  Edinb.,  1898,  11,  317-326. 

3.  Affleck,  J.  O.,  "  Edinburgh  Hospital  Reports,"  1894,  vol.  11,  pp.  198-238. 

4.  Alexander,  W.  C,  "A  Case  Illustrating  the  Difficulty  of  Diagnosis  in 
Gastric  Ulcer,"  "  Brit.  M.  J.,"  1897,  i,  1345. 

5.  Allen,  J.  E.,  "  Hereditary  Influence  or  Family  Tendency  as  a  Predispos- 
ing Cause  of  Gastric  Ulcer,"  "Yale  M.  J.,"  New  Haven,  1897-98,  iv,  229-232. 

6.  Altmann,  J.  P.,  "  Ulcer  of  the  Stomach,"  "  Tr.  M.  Soc.  Tennessee,"  Nash- 
ville, 1898,  105-113. 

7.  Anderson,  "British  Medical  Journal,"  May  10,  1890. 

8.  Anderson,  G.  R.,  "Note  on  a  Case  of  Perforated  Gastric  Ulcer,"  "  Brit. 
M.  J.,"  Lond.,  1898,  I,  1448. 

9.  Ardouin,  "  Ulcere  d'estomac,  Gastrotomie,"  "  Soc.  Anat.,"  17  Dec,  1897. 

10.  Assaky,  "Ulcer  stomacal,"  "  Spitalul  Bucuresci,"  1898,  xviii,  77-84. 

11.  Auffray,  "Contribution  a  I'etude,  du  diagnostic  de  la  peritonite 
suraigne  dans  I'ulcere  perforede  I'estomac,"  "  These  de  Paris,"  23  Juin,  1896. 

12.  Barling,  "Birmingham  Medical  Review,"  August,  1895. 

13.  Beck,  C,  "Medical  Record,"  Feb.  15,  1896. 

14.  Begoutn,  "Ulcere  latent  de  I'estomac;  perforation;  mort,"  "Journ.  de 
med.  de  Bordeaux,"  24  Janv.,  1897. 

15.  Bellrose,  N.  W.,  "Gastric  Ulcer,  Probably  Tubercular,  Report  of  a  Case," 
"Colorado  M.  J.,"  Denver,  1897,  in,  169-174. 

16.  Benedict,  A.  L.,  "Gastric  Ulcer,"  "Med.  News,"  N.  Y.,  1898,  Lxxiii, 
675-678. 

17.  Bensley,  C.  N.,  "A  Case  of  Chronic  Ulcer  of  the  Stomach,"  "Indian 
Lancet,"  Calcutta,  1897,  x,  171. 

18.  Berg,  A.  A.,  "The  Etiology  of  Gastric  Ulcer  and  an  Outline  of  Its 
Therapeutics,"  "Med.  Record,"  July  30,  1898. 

19.  Bernardbeig,  "  De  I'Ulcere  de  I'Estomac,"  "  Normandie  Med.,"  Rouen, 
1897,  XII. 

20.  Blackader,  A.  D.,  "Gastric  Catarrh  and  Gastric  Ulcer,"  "Am.  Text- 
book Dis.  Child."  (Stan.),  2d  ed.,  Phila.,  1898. 

21.  Bohland,  "  Ueber  die  Hernia  epigastrica  und  ihre  Folgezustande," 
"  Berl.  klin.  Wochenschr.,"  1894,  No.  34. 

22.  Bondet,  "  Gastrorrhagie  par  Ulcere  de  I'Estomac,  Traitement,"  "  Province 
Med.,"  Lyon,  1898,  xii,  380-383. 

23.  Borchgrevink,  "Ulcus  Ventriculi  Perforatum,  Laparotomie,"  "Norsk. 
Magaz.  f.  Laegevidensk,"  1897,  Heft  i. 


LITERATURE   ON   ULCER   OF   THE   STOMACH.  519 

24.  Bbttcher,  A.,  "  Zur  Genese  des  perforirenden  Magengeschwiirs," 
"  Dorpat.  med.  Zeitschr.,"  1874. 

25.  Bramwell,  B.,  "Clinical  Remarks  on  a  Case  of  Acute  Perforative 
Peritonitis  Due  to  Ulceration  of  the  Stomach,"  "  Internat.  Clin.,"  Phila.,  i8g8, 
8  s.,  I,  1 16-122. 

26.  Brenner,  "Zur  Magensecretion  bei  Ulcus  ventriculi,"  "Wiener  klin. 
Wochenschr.,"  No.  48,  1897. 

27.  Brinton,  W.  {loc.  cit.). 

28.  Broadbent,  W.,  "  Perforated  Gastric  Ulcer,"  "  Brit.  M.  J.,"  Lond.,  1897, 
III,  1254-1257. 

29.  Bugge,  "  Ulcer  of  the  Stomach  Causing  Death  by  Internal  Hemorrhage," 
"  Forh.  med.  Selsk.  i.  Kristiania,"  1897,  203-205. 

30.  Bush,  J.  Paul,  "  Cases  of  Perforative  Gastric  Ulcer  Treated  by  Opera- 
tion," "  Brit.  M.  Jour.,"  Nov.  5,  1898. 

31.  Cabot,  A.  T.,  "  A  Case  of  Perforating  Gastric  Ulcer;  Operation  at  End  of 
Twenty-four  Hours;  Recovery,"  "  Boston  M.  and  S.  Jour.,"  Aug.  11,  1898. 

32.  Cade,  "Ulcere  Perforant  de  I'Estomac  Chez  un  Enfant  de  Deux  Mois," 
"  Soc.  des  Scienc,  med.  de  Lyon,"  Oct.  20,  1897. 

33.  Cahn,  "Berlin,  klin.  Wochenschr.,"  1894,  No.  28. 

34.  Campbell,  J.,  "A  Case  of  Operation  for  Perforated  Gastric  Ulcer," 
"Brit.  Med.  Journal,"  July  16,  1898. 

35.  Caro,  "  Ueber  Blutungen  aus  Oesophagusvaricceen,"  Diss.,  Wiirzburg, 
Heidelberg,  1896. 

36.  Cathcart,  C.  W.,  "Ruptured  Gastric  Ulcer,"  "  Tr.  Med.-Chir.  Soc," 
Edinb.,  1896-97,  n.  s.,  xvi,  195. 

37.  Caussade,  "Ulceration  Gastrique,  Hematemese  Foudroyante,  Mort," 
"  Presse  Med.,"  30  Janvier,  H.  9. 

38.  Chaput,  "  Traitement  des  Ulceres  Gastriques,"  "  Gaz.  de  Hop.  Par.,"  1898, 
LXXI,  67. 

39.  Chaput,  "Ulcere  Gastrique  avec  Tumeur  Volumineuse,  Gastro-enteros- 
tomie,  Disparition  des  Accidents  et  Persistance  de  la  Tumeur,"  "Soc.  Med. 
des  Hopitaux,"  31,  i,  1897. 

40.  Chauffard,  "Ulcere  Simple  de  I'Estomac  avec  Hemorrhagies  Abon- 
dantes,  Guerison  ;  Mort  par  Coma  Diabetique,"  "Jour,  de  Med.  et  Chir.  Prat.," 
10  Mar.,  1898. 

41.  Choppin,  "  De  la  Perforation  dans  I'Ulcere  Latent  d'Estomac,"  "These 
de  Paris,"  1896. 

42.  Claisse,  "Ulcere  Rond  de  I'Estomac ;  Perforation;  Peritonite  Suraigue, 
Mort,"  "Soc.  Anat.,"  Paris,  8  Janvier,  1897. 

43.  Clubbe,  C.  P.  B.,  "  Four  Cases  of  Operation  for  Perforated  Gastric 
Ulcer,"  "Austral.  Med.  Gaz.,"  June  20,  1898. 

44.  Connelly,  A.  W.,  "Ulcer  of  the  Pyloric  Orifice,"  "  Intercolon.  M.  J. 
Austral.,"  Melbourne,  1898,  iii,  536-538. 

45.  Cramer,  "Ueber  die  Behandlung  des  Ulc.  ventr.  mit  grossen  Wismuth- 
dosen,"  "  Miinchener  med.  Wochenschr.,"  1896,  No.  25. 

46.  Cruveilhier,  "Anatomia  Pathologique,"  1829-1835,  Livraison  x. 

47.  Czygan,  "Zur  Behandlung  der  ulcusartigen  Magenerkrankungen," 
"  Therap.  Monatsschr.,"  Berl.,  1898,  Xll,  494-496. 

48.  Debove  et  Remond,   "  Traite  des  Maladies  de  I'Estomac,"  Paris,  p.  255. 

49.  Decker,  "  Exp.  Beitrag  zur  Aetiologie  der  Magengeschwiire,"  "  Berl. 
klin.  Wochenschr.,"  1887. 


520  ULCER   OF   THE   STOMACH. 

50.  Diddens,  E.  J.,  "  Een  paar  complicatier  van  het  maagulcus  en  haar- 
chirurgische  behandeling,"  "  Nederl.  Tijetschr.  v.  Geneesk.,"  Amst.,  1898,  2 
R.  XXXIV,  d.  2,  441-453. 

51.  Dieulafoy,  "  Ulceres  Latents  de  I'Estomac,"  "  Presse  Med.,"  25,  vii,  1897. 

52.  Dieulafoy,  "  Sur  I'Exulceratio  simplex  de  I'Estomac,"  "  Acad,  de  Med.," 
18  Janv.,  1898. 

53.  Dieulafoy,  "  Hematemese  dans  I'Exulceration  simplex,"  "Rev.  prat. 
d.  Trav.  de  Med.,"  Par.,  1898,  LX,  259. 

54.  Diriart  et  Apert,  "  Double  Ulcere  latent  de  I'Estomac,  double  perfora- 
tion, Laparotomie ;  Mort,"  "Soc.  Anat.,"  17,  i,  1896. 

55.  Dobson,  "Bristol  Medical  and  Surgical  Journal,"  1893,  p.  196. 

56.  Duplay,  "Sur  la  Traitement  operatoire  de  I'Exulceration  simple  de 
I'Estomac,"  "  Bull.  Acad,  de  Med.,"  Par.,  1898,  3  s.,  xxxix,  90-92. 

57.  Ebstein,  Wilh.,  "  Experimentelle  Untersuchungen  iiber  das  Zustande- 
bekommen  von  Blutextravasaten  in  der  Magenschleimhaut,"  "Arch.  f.  exp. 
Pathologie  u.  Pharm.,"  11,  1878. 

58.  Ebstein,  Wilh.,  "Ueber  die  Beziehungen  zwischen  Trauma  und  Magen- 
erkrankung,"  "  Deutsch.  Arch.  f.  klin.  Med.,"  Bd.  Liv. 

59.  Einhorn,  Max,  "  Medical  Record,"  June  23,  1894. 

60.  Elsasser,  "  Die  Magenerweichung  der  Sauglinge,"  Stuttgart  und 
Tubingen,  1846. 

61.  Etienne,  "  Ulcere  latent,"  "Soc.  de  Med.de  Nancy,"  11,  xi,  1896. 

62.  Ewald,  C.  A.  (Joe.  cit.),  p.  234;  "  Diseases  of  the  Stomach,"  p.  233. 

63.  Ewald,  C.  A.,  "  Klinik  der  Verdauungskrankheiten,"  i.  Theil,  3.  Aufl., 
p.  122. 

64.  Fanoe,  "  Fall  von  Ulcus  perforans  ventriculi,  durch  Laparotomie  und 
Sutur  geheilt,"  "  Hospital  stidende,"  52,  1896  (Casuistik). 

65.  Fenwick,  C,  "  A  Case  of  Gastric  Ulcer  Perforating  into  the  Pericardium," 
"Lancet,"  Lond.,  1897,11,  388. 

66.  Fenwick,  W.  S.,  "  Ulcer  of  the  Stomach  in  Children,"  "  Internat.  Clin.," 
Phila.,  1897,  7  s.,  II,  165-177. 

67.  Fischer,  O.,  "Bismuth  Treatment,"  Dissertation,  Jena,  1893. 

68.  Fisher,  H.  M.,"  Perforating  Round  Ulcer  of  the  Stomach,"  "  Tr.  Path. 
Soc,"  Phila.,  1898,  xviii,  46,  47. 

69.  Fleiner,  "Verhandl,  des  XIL  Congresses  f.  innere  Medicin,"  1893;  also 
"  Volkmann's  Vortrage,"  No.  103. 

70.  Flexner,  S.,  "  Exhibition  of  a  Specimen  of  Round  Ulcer  of  the  Stomach  ; 
Erosion  of  the  Gastric  Artery  ;  Postmortem  Perforation,"  "  Johns  Hopkins 
Hosp.  Bull.,"  Bait.,  1898,  ix,  41. 

71.  Fox,  Wilson,  "  The  Diseases  of  the  Stomach,"  1872,  p.  146. 

72.  Fyffe,  W.  K.,  "Gastric  Ulcer  with  Perforation,"  "  Australas.  M.  Gaz.," 
1897,  XVI,  331. 

73.  Gemiind,  "Beitiagezur  pathol.  Anatomie  des  Ulcus  ventriculi,  insbes. 
des  giirtelformigen,"  Dissert.,  Leipzig,  1895-96. 

74.  Glaeser,  A.,  "Ulcus  ventriculi  fiir  Aneurysma  gehalten,"  "  AUg.  med. 
Central-Ztg.,"  Berl.,  1897,  Lxvi,  561. 

75.  Godart-Danhieux,  "  I'Emploi  des  Alcalins  dans  I'Ulcere  de  I'Estomac," 
"Policlin.  Brux.,"  1898,  vii,  33-43. 

76.  Gongora,  J.,  "  Acerca  del  tratamiento  farmacologico  de  la  ulcera  cronica 
simple  del  estomago,"  "  Rev.  de  cier.  med.  de  Barcel.,"  1897,  xxiii,  t.  2,  401- 
408. 


LITERATURE   ON   ULCER   OF   THE   STOMACH.  52 1 

"JT .  Griffini  und  Vassale,  "  Beitrage  zur  patholog.  Anat.,"  von  Ziegler  und 
Nauwerck,  Bd.  in,  Heft  5,  p.  425. 

78.  Griffini  und  Vassale,  "  Ueber  die  Reproduction  der  Magenschleimhaut," 
"  Ziegler's  Beitrage,"  in. 

79.  Gijnzburg,  "  Zur  Kritik  des  Magengeschwiirs,"  "Arch,  fiir  physiol. 
Heilkunde,"  ix. 

80.  Hainebach,  J.,  "  Zwei  Falle  von  Perigastritis  adhaesiva  nach  Ulcus 
ventriculi,"  "Deutsche  med.  Wochenschr.,"  Leipz.  u.  Berl.,  1897,  xxiii,  657- 
660. 

81.  Hall,  A.  J.,  "On  Two  Cases  ot  Perigastric  Abscess  Arising  from  Gastric 
Ulceration  and  Rupturing  into  the  Left  Lung,"  "  Clin.  Jour.,"  London,  1898, 
XII.  353-357- 

82.  Hamilton,  H.  L.,  "  Treatment  of  a  Case  of  Gastric  Ulcer,"  "Louisville 
Med.  Monthly,"  1898-99,  v,  131. 

83.  Hartmann,  "  Peritonite  par  Perforation  d'un  Ulcere  Simple  de  I'Estomac, 
Laparotomie ;  Guerison,"  "Bull,  de  la  Soc.  de  Chir.,"  Bd  xxii,  1896. 

84.  Hartmann,  "  Ulcere  de  I'estomac  ;  gastro  enterostomie,"  "  Soc.  de  Chir," 
20  aout,  1897. 

85.  Harttung,  O.,  "  Ueber  Faltenblutungen  und  hamorrhagische  Erosionen," 
"  Deutsche  med.  Wochenschr.,"  1890,  No.  38,  p.  847. 

86.  Hauser,  "  Das  chronische  Magengeschwur,"  Leipzig,  1883. 

87.  Heidenreich,  "  Del'Intervention  Chirurgicale  dans  I'Ulcere  d'Estomac," 
"  Sem.  Med.,"  2  fevrier,  1898. 

88.  Herald,  J.,  "Ulcer  and  Cancer  of  the  Stomach,"  "  Kingston  Med.  Quart.," 
1897-98,  II,  124-128. 

89.  Herrick,  J.  B.,  "  The  Treatment  of  Ulcer  of  the  Stomach  by  Rest  in  Bed 
and  Rectal  Feeding,"  "Jour.  Amer.  Med.  Asso.,"  1898,  xxxi,  1303. 

90.  Hibbard,  C.  M.,  "  A  Case  of  Gastric  Ulcer  in  a  Child  Four  Months  Old," 
"  Boston  Med.  and  Surg.  Jour.,"  1897,  cxxxvii,  177. 

91.  Hirsch,  "  Zur  Casuistik  und  Therapie  der  lebensgefahrlichen  Magenblut- 
ungen,"  "Berl.  klin.  Wochenschr.,"  No.  38,  1896. 

92.  Hoffmann,  "Ueber  die  Erweichung  und  den  Durchbruch  der  Speiserohre 
und  des  Magens,"  "  Virchow's  Archiv,"  Bd.  XLiv. 

93.  Hone,  F.  S.,  "  Gastric  Ulcer  and  Secondary  Parotiditis,"  "  Australas.  Med. 
Gaz.,"  Sydney,  1898,  xvii,  50-54. 

94.  Hood,  D.,  "A  Case  of  Gastric  Ulcer,"  "Clin.  Jour.,"  London,  1898-99, 
xiii,  136. 

95.  Horner,  "  Cardialgie  durch  Einklemmung  praperitonealer  Lipome," 
"  Prager  med.  Wochenschr.,"  1892. 

96.  Jacot-Descombes,  Ch.,  "  Contribution  anatomique  a  I'etude  de  la  patho- 
genic de  I'ulcererond  de  I'estomac,"  "These  de  Paris,"  1897. 

97.  James,  A.,  "Gastric  Ulcer,"  "Internal.  Clin.,"  Philadelphia,  1898,  8  s., 
126-135. 

98.  Jaworski  und  Korczynski,  "  Deutsche  med.  Wochenschr.,"  1886,  Nos. 

47-49- 

99.  Jonas,  A.  F.,  "  Operation  for  Ulcus  Ventriculi  Chronicum,  Three  Cases, 
with  Remarks  on  Indications  for  Operation,"  "West.  Med.  Rev.,"  Lincoln, 
Neb.,  1897,  II,  285-287. 

100.  Jones,  Eleanor  C,  "A  Case  of  Gastric  Ulcer  Terminating  in  Hemor- 
rhage and  Death,"  "  Med.  News,"  New  York,  1897,  Lxxi,  499. 


52  2  ULCER   OF   THE   STOMACH. 

loi.  Key,  Axel,  "  Gurlt-Virchow's  Jahresb.,"  1871. 

102.  Klaussner,  "  Ein  Beitrag  zur  operativen  Behandlung  des  Ulcus  ven- 
triculi,"  "Miinch.  med.  Wochenschr.,"  1897,  No.  37, 

103.  Kohler,  "Beitrag  zur  Kenntniss  der  Symptomatologie  bei  Ulcus  ven- 
triculi  simplex,"  Dissert.,  Berlin,  1895-96. 

104.  Kolisch,  R.,  "Zur  Frage  der  posthamorrhagischen  Azoturie  (speciell 
beim  Ulcus  ventriculi),"  "  Wien.  klin.  Wochenschr.,"  1897,  x,  628. 

105.  Krokiewicz,  A.,  "  Ein  Beitrag  zur  Lehre  vom  runden  Magengeschwiir," 
"Wien.  klin.  Wochenschr.,"  1897,  x. 

106.  Krupetski,  Aleksiei,  "  Kucheniga  ob  Ulcus  ventriculi  rotundum,"  "  Yur- 
yev,"  1897,  K.  Matisen,  256,  p.  8. 

107.  Laine,  J.,  "Des  erosions  hemorrhagiques  de  I'estomac,"  "These  de 
Paris,"  17  Novembre,  1897. 

108.  Lammert,  "  Das  perforierte  Ulcus  ventriculi  rotundum  in  gerichtlich- 
medicinischer  Beziehung,  nebst  Bemerkungen  iiber  die  Haufigkeit  des  runden 
Magengeschwiirs  zu  Munchen  in  den  Jahren  1883-88,"  Dissert.,  Miinchen, 
1895-96. 

109.  Landerer,  A.,  und  G.  Glucksmann,  "  Mittheilungen  aus  den  Grenz- 
gebieten  der  Medizin  und  Chirurgie,"  Bd.  i,  p.  168,  Jena,  1896. 

no.  Langerhaus,  "  Virchow's  Archiv,"  Bd.  cxxiv,  p.  373. 

111.  Lanzer,  O.,  "  Zur  Diagnose  und  Therapie  des  runden  Magengeschwiirs," 
"Wien.  med.  Presse,"  1898,  xxxix,  1127-1131. 

112.  Lanenstein,  "Arch.  f.  klin.  Chirurgie,"  vol.  xiv, 

113.  Leblanc,  "Gastrorrhagie  et  perforation  dans  I'ulcere  de  I'estomac,'' 
"These  de  Paris,"  3,  xii. 

114.  Leith,  R.  F.  C,  "  Edinburgh  Hospital  Reports,"  1894,  vol.  11,  pp.  198- 
238. 

115.  Lennander,  K.  G.,  "The  Treatment  of  the  Perforating  Stomach  and 
Duodenal  Ulcer,"  "Upsula  Lakaref.  Forh.,"  1897-98,  N.  F.,  iii,  350-403. 

116.  Levi,  "  Retrecissement  fibreux  du  pylore  consecutif  a  un  ulcere  de 
I'estomac,"  "  Soc.  Anat.  de  Paris,"  31,  i,  1897. 

117.  Le  Wald,  L.  U.,  "Ulceration  of  Both  Stomach  and  Duodenum,  with 
Perforation  of  the  Splenic  Artery,"  "Med.  Rec,"  New  York,  1898,  Liv, 
892. 

118.  Leyden,  E.,  "  Ueber  Pyopneumothorax  subphrenicus  und  subphren- 
ische  Abscesse,"  "  Zeitschr.  f.  klin.  Med.,"  1880,  p.  320. 

119.  Liebermeister,  "Ueber  das  einfache  Magengeschwiir,"  "Volkmann's 
Sammlung  klin.  Vortrage,"  1892,  No.  61. 

120.  Lincoln,  J.  R.,  "Gastric  Ulcer  in  the  Newborn;  Etiology,  Maternal 
Impressions,"  "Boston  Med.  and  Surg.  Jour.,"  1897,  cxxxvii,  178. 

121.  Litten,    "Ulcus   ventriculi   tuberculosum,"    "Virchow's   Archiv,"  Bd. 

LXVII. 

122.  Liitzeler,  "  Statistisches  iiber  Magengeschwiire  und  operative  Eingrifife 
bei  denselben,"  Dissert.,  Bonn,  1895-96. 

123  Luys,  G.,  "Ulceration  gastriques  chez  un  alcoolique  mort  subite  par 
hemorrhagic, "  "  Bull.  Soc.  Anat.  de  Par.,"  1896,  lxxi,  660-667. 

124.  Lyell,  "A  Case  of  Gastric  Ulcer  with  Perforation  in  Two  Places," 
"  Brit.  Med.  Jour.,"  London,  1898,  I,  818. 

125.  Lyon,  G.,  "Traitement  de  I'ulcere  simple  de  restomac,"  "  Gaz.  d. 
Hop.,"  Paris,  1898,  3  s.,  xv,  356-358. 


LITERATURE   ON   ULCER   OF   THE   STOMACH.  523 

126.  Lyon,  "Discussion  sur  le  traitement  de  I'ulcere  de  I'estomac,"  "Bull, 
gen.  de  therap.,"  etc.,  Paris,  1898,  cxxxvi. 

127.  Mackenzie,  J.,  "A  Case  of  Gastric  Ulcer  with  Characteristic  Seat  of 
Pain,"  "  Edinb.  Med.  Jour.,"  1897,  n.  s.,  11,  591, 

128.  Mackenzie,  J.,  "The  Site  of  Pain  in  Gastric  Ulcer,"  "Edinb.  Med. 
Jour.,"  1897,  n.  s.,  II,  154-158. 

129.  Mackenzie,  W.  G.,  "Perforation,  Ulcer  of  Stomach  with  Hour-glass 
Contraction,"  "  Tr.  Path.  Soc,"  London,  1896-1897,  XLViii. 

130.  Marcet,  "  Medico-Chirurgical  Transactions,"  vol.  xil,  p.  72. 

131.  Marchand,  "  Gastromalacie  (und  CEsophagomalacie),"  "  Real-Encyklo- 
padie,"  xii. 

132.  Marcille,  "Ulcere  gastrique;  abces  de  la  rate,  abces  sous  phrenique," 
"Soc.  Anat.,"  Paris,  10  juin,  1898. 

133.  Marin  Perujo,  "  Ulceration  del  estomago  por  el  uso  inadecuado  de  la 
quinina,"  "  Siglo  med.,"  Madrid,  1897,  XLIV,  706. 

134.  Matthes,  "Ueber  den  Vorschlag  Fleiner's,  Reizerscheinungen  des 
Magens  mit  grossen  Dosen  Wismuth  zu  behandeln,"  "  Centralblatt  fiir  innere 
Med.,"  1894. 

135.  Mauwerk,  C,  "Gastritis  ulcerosa  chronica,  ein  Beitrag  zur  Kenntnis 
des  Magengeschwiirs,"  "  Miinch.  med.  Wochenschr.,"  1897,  xliv,  955,  987. 

136.  Mayer,  W.,  "  Gastromalacia  ante  mortem,"  "  Deutsches  Arch,  fiir  klin. 
Med.,"  IX,  1872. 

137.  McCohs,  A.  J.,  "A  Case  of  Perforating  Gastric  Ulcer;  Operation, 
Recovery,"  "Med,  News,"  16,  i,  1897. 

138.  Metcalfe,  W.  B.,  "Etiology  and  Diagnosis  of  Ulcer  of  the  Stomach," 
Matthews,  O.  J.,  "Rectal  Dis.,"  Louisville,  1897,  iv,  335-344. 

139.  Merigot  de  Freigny,  "  Traitement  de  I'ulcere  Gastrique  par  le  repos 
absolu  de  I'Estomac,"  "  Rev.  gen.  de  clin,  et  de  Therap,"  Par.,  1897,  xr,  517- 
520. 

140.  Mintz,  "Operative  Behandlung  der  Magenkrankheiten,"  "  Zeitschr.  f. 
klin.  Med.,"  Bd.  xxv,  1894. 

141.  Morely,  "Ulcere  rond  de  I'Estomac  d'evolution  lente.  Perforation 
peritonite  generalisee,"  "Soc.  Anat.,"  10  Dec,  1897. 

142.  Miiller,  L.,  "  Das  corrosive  Geschwiir  im  Magendarmkanal,"  Erlangen, 
i860. 

143.  Murrell,  W.,  "Gastric  Ulcer  and  Its  Treatment,"  "Med.  Brief,"  St. 
Louis,  1898,  XXVI,  673-676. 

144.  Neuwerck,  C,  "  Ueber  den  mycotischen  Ursprung  des  peptischen 
Magengeschwiirs,"  "  Miinchener  med.  Wochenschr.,"  1895. 

145.  Nissen,  "Zur  Frage  der  Indication  der  operativen  Behandlung  des 
runden  Magengeschwiirs,"  "Petersburger  med.  Wochenschr.,"  1890. 

146.  Nitka,  "  Ueber  embolische  Magengeschwiire,"  Dissert.,  Freiburg  i, 
Br.,  1895-96. 

147.  V.  Noorden,  "  Magensaftsecretion  und  Blutalkaleszenz,"  "  Arch,  fiir 
exp.  Pathologie  u.  Pharm." 

148.  V.  Noorden,  "  Zwei  operative  Eingriffe  wegen  Folgezustanden  von 
Magengeschwiiren,"  "Miinch.  med.  Wochenschr.,"  No.  35,  1896. 

149.  Nolte,  see  Ewald  {loc.  cit.,  239). 

150.  O'Donovan,  C,  "On  the  Treatment  of  Gastric  Ulcers  after  Hemor- 
rhage," "New  York  Med.  Jour.,"  1897,  Lxvi,  51-53. 


524  ULCER   OF   THE   STOMACH. 

151.  Oliver,  F.,  "  Ulceration  of  the  Pylorus  and  Its  Consequences,"  "  Inter- 
nal. Clin.,"  Philadelphia,  1898,  8  s.,  i,  146-157. 

152.  Openchowski,  "  Zur  pathologischen  Anatomic  der  geschwiirigen  Pro- 
cesse  im  Magendarmtractus,"  "  Virchow's  Archiv,"  Bd.  cxvii. 

153.  Panum,  "  Experimentelle  Beitrage  zur  Lehre  von  der  Embolie,"  "Vir- 
chow's Archiv,"  Bd.  xxv,  1862. 

154.  Pariser,  "  Die  Behandlung  des  frei  in  die  Bauchhohle  perforierten  Ulcus 
ventriculi,"  "  AUg.  medic.  Centralz.,"  1896. 

155.  Pauly,  "Zur  Lehre  vom  traumatischen  Magengeschwur,"  "  Aerztl. 
Sachverst.-Ztg.,"  No.  2,  1898. 

156.  Pavy,  "On  Gastric  Erosion,"  "Guy's  Hospital  Reports,"  vol.  xiv, 
1868. 

157.  Petruschky,  J.,  "  Zur  Diag.  u.  Therap.  d.  Primar.  Ulcus  ventric.  tubercu- 
losum,"  "  Verhandlung  d.  XVII.  Congress,  f.  innere  Medicin,"  1899,  S.  366. 

158.  Pfuhl,  "  Berliner  klin.  Wochenschr.,"  1877,  p.  57. 

159.  Potain,  "Ulcere  Simple  Duodenal  et  Ulcere  Simple  de  I'Estomac," 
"  Bull,  med.,"  i,  i,  1897. 

160.  Poulain,  "  Du  role  de  I'lnfection  dans  la  Pathogenie  de  I'Ulcere  rond," 
"These  de  Paris,"  1897. 

161.  Qaife,  F.  H.,  "  An  Interesting  Case  of  Gastric  Ulcer,"  "  Australas.  Med. 
Gaz.,"  1898,  XVII. 

162.  Quincke,  "Die  Entstehung  des  Magengeschwiirs,"  "Deutsche  med. 
Wochenschr.,"   1882. 

163.  Quincke  und  Daettwyler,  "  Correspondenzbl.  f.  Schweizer  Aerzte,''  1875, 
p.  lOI. 

164.  Rabe  et  Rey,  "  Double  Ulcere  de  I'Estomac;  Ulceration  du  foie  et  du 
Pancreas,  Retraction  Cicatricielle  Intense,  avec  Biloculation  de  I'Estomac; 
Abces  sus-hepato-phrenique,  Epanchement  Pleuritique  Double,  Purulent  a 
Gauche,  Sereux  a  Droite,"  "  Bull.  Soc.  Anat.  de  Par.,"  1897,  lxxii. 

165.  Rasmussen,  "  Ueber  die  Magengeschwiirfurche  und  die  Ursache  des 
chronischen  Magengeschwurs,"  "  Centralblatt  fiir  die  med.  Wissenschaften," 
1887. 

166.  Ratjen,  "Ulcus  ventriculi,  ausschliesslich  mit  Rectal-Ernahrung  be- 
handelt,"  "Deutsche  med.  Wochenschr.,"  No.  52,  1897. 

167.  Reichel,  "Zur  Lehre  vom  traumatischen  Magengeschwur,"  "Aerztl. 
Sachverst.-Ztg.,"  Nr.  6,  1898. 

168.  Riegel,  F.,  "  Zeitschr.  f,  klin.  Med.,"  Bd.  xii,  S.  434,  and  "Deutsche 
med.  Wochenschr.,"  1886,  Nr.  52. 

169.  Rindfleisch,  "  Lehrbuch  der  patholog.  Anatomic." 

170.  Ritter,  "Ueber  den  Einfluss  von  Traumen  auf  die  Entstehung  des 
Magengeschwurs,"  "  Zeitschr.  f.  klin.  Med.,"  xii. 

171.  Rivet,  "  Perforation  par  ulcere  de  I'estomac,"  "  Soc.  med.  de  Nantes," 
10  Dec. ;  "Gaz.  med.  de  Nantes,"  1897. 

172.  Rokitansky,  "  Lehrbuch  der  patholog.  Anatomic." 

173.  Rolleston,  H.  D.,  "  A  Case  of  Latent  Ulcer  of  the  Pylorus  with  Jaun- 
dice, Simulating  Malignant  Disease,"  "  Practit.,"  London,  1897,  Liv,  465-470. 

174.  Rommelaere,  "  Ulcere  rond  phagedenique  de  I'estomac  deux  lesions, 
une  cicatrice  a  fond  pancreatiquc  et  un  ulcere  perforant  en  activite  bouchc 
par  un  cartilage  costal,  sclerose  dc  la  parvi  prepylorique  ;  mort,  autopsie," 
"Clinique  Brux.,"  1897,  xi,  521-529. 


LITERATURE   ON   ULCER   OF   THE   STOMACH.  525 

175.  Rosenheim,  Th.,  "  Pathologie  und  Therapie  der  Krankheiten  der 
Speiserohre  und  des  Magens,"  Wien  und  Leipzig,  1891,  S.  161. 

176.  Rosenheim,  Th.,  "  Zur  Kenntniss  des  mit  Krebs  complicirten  runden 
Magengeschwiirs,"  "  Zeitschr.  f.  klin.  Med.,"  Bd.  xvii,  S.  116. 

177.  Rosenheim,  Th.,  "  Deutsche  med.  Wochenschr.,"  1890,  Nr.  15. 

178.  Rosenheim,  "Die  neueren  Behandlungsmethoden  des  Magens,"  "Ber- 
liner Kiinik,"  May,  1894. 

179.  Roughton,  E.  W.,  "Perforating  Gastric  Ulcer;  Operation,  Death; 
Necropsy,"  "  Brit.  Med.  Jour.,"  July  9,  1898. 

180.  Sansoni,  L,,  "  II  sottonit  rato  di  bismuto  ad  alte  dosi  nella  cura  del 
I'ulcera  semplice  dello  stomaco,"  "  Gior.  d.  r.  accad.  di  med  di  Torino,"  1897, 
3  s.,  XLV,  463-468. 

181.  Saundby,  "  Ein  Fall  von  sanduhrformiger  Einschnlirung  des  Magens 
in  Verbindung  mit  einem  kolossalen  Magengeschwur,"  "  Deutsche  med. 
Wochenschr.,"  1891. 

182.  Saveliefif,  "  Ueber  die  Wismuthbehandlung  des  runden  Magenge- 
schwiirs," "  Therap.  Monatshefte,"  1894,  Nr.  10. 

183.  Scheel,  V.,  "  Et  Tifaelde  af  Ulcus  ventriculi,"  "  Hosp.-Tid.  Kjobenh.," 
1898,  4.  R.,  VI. 

184.  Scheurmann,  "  Ueber  die  Haufigkeit  des  runden  Magengeschwiirs  in 
Miinchen,"  Dissert.,  Miinch.,  1895-96. 

185.  Schiff,  "  Beitrag  zur  Kenntniss  des  motorischen  Einflusses  der  im  Seh- 
hiigel  vereinigten  Gebilde,"  "  Arch.  f.  physiol.  Heilkunde,"  v,  1846. 

186.  Schiff,  "Ueber  die  Gefassnerven  des  Magens,"  ibid.,  xiii,  1854,  S.  30. 

187.  Schmidt,  "  Anatomische  Beitrage  zur  Genese  des  Ulcus  ventriculi," 
Dissert.,  Leipzig,  1895-96. 

188.  Schiitz,  R.,  "  Differential-Diagnose  d.  Ulcus  ventriculi,"  ibid.,  S.  417. 

189.  Sehrwald,  "Was  verhindert  die  Selbstverdauungdes  lebenden  Magens? 
Ein  Beitrag  zur  Aetiologie  des  runden  Magengeschwiirs,"  "  Miinch.  med. 
Wochenschr.,"  1888. 

190.  Shaw,  G.  F.,  "  Hematemesis  as  a  Sequence  of  Chronic  Ulcer,"  "  Med. 
Rec,"  New  York,  1898,  liv,  138. 

191.  Silbermann,  "  Deutsche  med.  Wochenschr.,"  1886,  Nr.  29. 

192.  Sohlern,  V.,  "  Der  Einfluss  der  Ernahrung  auf  die  Entstehung  des 
Magengeschwiirs,"  "  Berl.  klin.  Wochenschr.,"  1889,  Nr.  14. 

193.  Stawell,  R.  deS.,  "  Perforating  Gastric  Ulcer,"  "  St.  Barth.  Hosp.  Jour.," 
London,  1897-98,  v. 

194.  Stepp,  "Zur  Behandlung  des  chronischen  Magengeschwiirs,"  "  Ver- 
handlungen  der  65.  Versammlung  deutscher  Naturforscher  und  Aerzte,"  1893. 

195.  Sticker,  "Ueber  den  Einfluss  der  Magensaftabsonderung  auf  den 
Chlorgehalt  des  Harns,"  "  Berl.  klin.  Wochenschr.,"  1887. 

196.  Sticker  und  Hubner,  "  Wechselbeziehungen  zwischen  Secreten  und 
Excreten,"  "Zeitschr.  f.  klin.  Med.,"  xii,  1887. 

197.  Stockton,  Chas.  G.,  "The  Etiology  of  Gastric  Ulcer,"  "Med.  News," 
Jan.  14,  1893. 

198.  Sutherland,  L.  R.,  "A  Series  of  Specimens  of  Perforating  Ulcer  of  the 
Stomach  and  Duodenum,"  "Glasgow  Med.  Jour.,"  1898,  XLix,  207-215. 

199.  Talma,  "  Untersuchungen  iiber  Ulc.  ventr.  simpl.  Gastronialacie  und 
Ileus,"  "  Zeitschr.  f.  klin.  Med.,"  xvn,  1890. 

200.  Taylor,  S.,  "  Gastric  Ulcer,"  "  Med.  Press  and  Circ,"  London,  1898, 
n.  s.,  Lxv,  297-300. 


526  ULCER   OF   THE   STOMACH. 

201.  Thorspecken,  "  Ein  Fall  von  Magenerweichung  ante  mortem," 
"  Deutsches  Arch.  f.  klin.  Med.,"  xxxiii, 

202.  Tournier,  C,  "  D'un  type  de  catarrhe  gastrique  avec  hyperesthesia  de 
la  muqueuse  et  colite  mucomembraneuse ;  difficultes  diagnostiques  avec 
Tulcere,"  "Province  med.,"  Lyon,  1898,  xii,  457-461. 

203.  Troisfontaines,  "Ulcere  simple  de  I'estomac,  chez  une  jeune  homme; 
mort ;  examen  anatomique,"  "  Ann.  de  la  Soc.  de  med.  de  Liege,"  Juin,  1896. 

204.  Tuffier,  "  Epaississement  des  parois  stomacales  du  a  un  ulcere  prob- 
able," "  Soc.  de  Chir.,"  27  Oct.,  1897. 

205.  Uhlrich,  Chr.,  "Sequelae  ulceris  ventriculi  perforati,"  "  Biblioth.  for 
Laeger,"  p.  367. 

206.  Vasilin,  C,  "  Ulcerul  simplu  al  stomac  uli  si  tratamentul  Boas," 
"Spitalul,"  Bucuresci,  1898,  xvir. 

207.  Virchow,  R.,  "  Virchow's  Archiv,"  Bd.  v,  p.  363. 

208.  Von  Leube  und  Mikulicz,  "  Chirurgische  Behandlung  des  Magenge- 
schwiirs,"  Abstr.  "  Deutsche  med.  Wochenschr.,"  1897,  xxiii,  Ver.  Beil.,  83. 

209.  Warren,  J.  C,  "  The  Surgery  of  Gastric  Ulcer,  with  the  Report  of  a 
Case  of  Gastrolysis,"  "  Boston  Med.  and  Surg.  Jour.,"  Sept.  29,  1898. 

210.  Weir,  Robt.  F.,  and  E.  M.  Foote,  "The  Surgical  Treatment  of  Round 
Ulcer  of  the  Stomach  and  Its  Sequelae,  with  an  Account  of  a  Case  Successfully 
Treated  by  Laparotomy,"  "  Med.  News,"  April  25  and  May  2,  1896. 

211.  Welch,  cited  from  Osier's  "  Practice  of  Medicine,"  p.  369. 

212.  Welti,  "  Drei  Falle  von  Verbrennungstod,"  "  Centralblatt  fiir  allg. 
Path.,"  1890. 

213.  Widal  et  Meslay,  "Ulcere  rond  developpe  au  cours  dune  pyhemie  a 
staphylocoques  ;  de  lorigine  infectieuse  de  certains  ulceres  ronds  perforants  de 
I'estomac,"  "Bull,  et  mem.  Soc.  med.  d.  hop.  de  Par.,"  1897,  3  s.,  xiv,  pp. 

379-385- 

214.  Winternitz,  W.,  "  Die  Hydrotherapie  des  Ulcus  rotundum  ventriculi," 
"  Deutsche  med.  Wochenschr.,"  Nr.  46,  1897. 

215.  Wynter,  W.  E.,  "On  Gastric  Ulcer  Treatment,"  London,  1897,  i,  462- 
464. 

2i6.  Ziemssen,  "  Ueber  die  Behandlung  des  einfachen  Magengeschwiirs," 
"  Volkmann's  Sammlung  klinischer  Vortrage,"  1871,  Nr,  15. 

We  refer  also  to  "  Literature  on  Gastric  Ulcer  "  in  Prof.  William  H.  Welch's 
article  in  "American  System  of  Medicine,"  vol.  11,  p.  480,  in  which  over  140 
important  bibliographical  references  are  given. 

In  the  fourth  volume  of  Penzoldt  and  Stintzing's  "  Handbuch  d.  speciellen 
Therapie,"  vol.  iv,  pp.  316,  317,  also  pp.  437  and  438,  are  contained  150  biblio- 
graphical references  on  the  treatment  of  Gastric  Ulcer. 

BIBLIOGRAPHY  OF  ULCUS  CARCINOMATOSUM. 

1.  Berthold,  Inaug. -Dissert.,  Berlin,  1883. 

2.  Biach,  "  Wien.  med.  Presse,"  1890,  Nr.  3. 

3.  Boas,  "  Diagnostik  u.  Therapie  d.  Magenkrankh.,"  p.  8. 

4.  Bouveret,  "  Traite  de  malad.  d.  I'estomac,"  Paris,  1893,  p.  274  (three 
cases). 

5.  Brinton,  "  Lectures  on  Diseases  of  the  Stomach,"  London,  1864. 

6.  Diitrich,  "  Prager  Vierteljahresschrift,"  v,  1848,  S.  i. 


BIBLIOGRAPHY    OF    ULCUS    CARCINOMATOSUM.  527 

7.  Eisenlohr,  "  Deutsche  med.  Wochenschr.,"  1890,  Nr.  52, 

8.  Ewald,  "  Klinik  d.  Verdauungskrankh.,"  1885. 

9.  Feiertag,  Inaug. -Dissert.,  Dorpat,  1894. 

10.  Hauser,  "  Das  chronische  Magengeschwiir,"  Leipzig,  1883. 

11.  Heitler,  "  Wien.  med.  Wochenschr.,"  1883,  Nr.  31. 

12.  Koch,  R.,  "  St.  Petersburger  med.  Wochenschr.,"  1893,  Nr.  43. 

13.  KoUmann,    "  Zur   Differentialdiagnose   zwischen    Magengeschwiir   und 
Magenkrebs,"  1891,  Nr.  5,  6. 

14.  Krukenberg,  Inaug. -Dissert.,  Heidelberg,  1888. 

15.  Kulcke,  Inaug. -Dissert.,  Berlin,  1889. 

16.  Langguth,  "  Archiv  f.  Verdauungskrankh.,"  von  Boas,  Bd.  i,  S.  355,  "On 
Significance  of  Lactic  Acid." 

17.  Lebert,  "  Die  Krankheiten  d.  Magens,"  Tubingen,  1878,  S.  440. 

18.  Leube,  "  Ziemssen's  Handbuch,"  Bd.  vii,  S.  124. 

19.  Meyer,  C,  Inaug. -Dissert.,  Heidelberg,  1885. 

20.  Oppler  und  Boas,  "  Zur  Kenntniss  d.  Mageninhaltsb.  Carcinome,"  etc., 
"  Deutsche  med.  Wochenschr.,"  1895,  Nr.  5. 

21.  Pignal,  "These  de  Lyon,"  1891  (two  cases). 

22.  Plange,  Inaug. -Dissert.,  Berlin,  1859. 

23.  Riegel,  F.,  "  Die  Erkrankungen  d.  Magens,"  p.  174.     (On  the  Oppler- 
Boas  bacillus.) 

24.  Rokitansky,  "  Lehrbuch  d.  patholog.  Anatomie,"  third  edition. 

25.  Rosenheim,  "Zur  Kenntniss  des  mit  Krebs  complicirten  runden  Magen- 
geschwurs,"  "  Zeitschr.  f.  klin.  Med.,"  Bd.  xvii,  S.  116. 

26. 'Schlesinger   und  Kaufmann,  "Wien.  klin.  Rundschau,"   1895,   Nr.  15. 
(On  the  Oppler-Boas  bacillus.) 

27.  Steiner,  Inaug. -Dissert.,  Berlin,  1868. 

28.  Sticker,  "  Verhandl.  d.  Congresses  f.  innere  Med.,"  1887. 

29.  Tapret,  "  Union  medic,"  1891,  No.  98. 

30.  Thiersch,  "  Miinch.  med.  Wochenschr.,"  1886,  Nr.  13. 

31.  Waltzold,  "  Charite-Annalen,"  Bd.  xiv. 

32.  WoUmann,  Inaug.-Dissert.,  1868. 


CHAPTER  IV. 

MALIGNANT  TUMORS  OF  THE  STOMACH. 

(A)  CARCINOMATA. 
Pathology. — In  accordance   with   leading  pathologists   we  may 
distinguish  four  types: 

1 .  The  cylindrical  cell,  or  adenocarcinoma. 

2 .  The  soft  glandular,  or  medullary  carcinoma. 

3.  The  hard  glandular  carcinoma,  or  scirrhus. 

4.  The  mucous,  or  colloid  carcinoma. 

35 


528  MAUGNANT   TUMORS    OF   THE    STOMACH. 

In  the  section  on  the  Surgical  Operations  on  the  Stomach  we  have 
spoken  of  the  relative  frequency  with  which  these  various  types  of 
carcinoma  attack  this  organ.  It  is  an  error  for  clinicians  to  speak  of 
gastric  cancer  as  if  this  were  the  only  type  of  malignant  neoplasm 
that  can  attack  the  stomach.  Inasmuch  as  these  various  types  show 
different  rates  of  mortality  after  operation,  and  as  they  can  occa- 
sionally be  distinguished  clinically  by  small  bits  of  the  new  growth, 
which  come  up  in  the  wash-water  or  are  found  caught  in  the  eyes  of 
the  stomach-tube,  it  is  essential  that  a  brief  pathological  description 
of  them  should  be  given.  The  types  which  we  have  mentioned  are 
not  sharply  distinguished  from  each  other,  but  many  gradations  and 
transitions  exist  between  them.  The  structure  of  a  gastric  malignant 
neoplasm  is  by  no  means  a  matter  of  indifference,  both  for  the  clinical 
history  and  the  prospective  surgical  treatment.  The  scirrhus  ex- 
hibits the  most  protracted  course;  the  medullary  (soft  glandular)  a 
disposition  to  disintegration  and  formation  of  metastases ;  while  the 
colloid  has  a  tendency  to  extend  to  the  peritoneum,  and  rarely  forms 
metastases. 

The  cylindrical  cell,  or  adenocarcinoma,  presents  a  soft,  distinct 
prominence,  or  tumor,  upon  the  surface  of  which  smaller  fungoid 
elevations  develop,  being  attached  to  the  fundamental  tumor  by 
broad  or  narrow  bases,  which  give  the  surface  a  papillary  appearance. 
In  this  case  the  tumor  regularly  has  a  red  color,  because  each  individ- 
ual fungosity  contains  a  small  loop  of  blood-vessels.  The  little 
vessels  in  the  outer,  as  well  as  those  in  the  inner,  sections  of  the  neo- 
plasm frequently  show  an  irregular  spindle-shaped  or  spherical  dilata- 
tion, so  that  this  form  of  carcinoma  has  been  called  by  Orth,  telan- 
giectatic. This  condition  of  the  blood-vessels  may  explain  why,  in 
this  type  of  cancer,  smaller  or  larger  extravasations  of  blood  are 
found  on  the  surface,  as  well  as  in  the  parenchyma ;  and  also  accounts 
for  the  frequent  effusion  of  blood  into  the  cavity  of  the  stomach.  On 
section,  the  so-called  "carcinoma  juice"  appears  abundantly  on  the 
surface,  and  in  this  "juice"  typical  cylindrical  cells  are  generally 
exclusively  found  in  sections  examined  microscopical^.  Such  sec- 
tions present  varying  pictures,  according  to  whether  they  are  taken 
from  the  surface  or  from  deeper  regions  of  the  neoplasm.  On  the 
surface  the  aspect  closely  resembles  that  of  a  papillary  fibroma,  but 
in  the  deeper  regions  a  glandular  structure  becomes  very  distinct,  for 
here  cylindrical  cells  may  be  seen  lining  tubular,  hollow  spaces  in  a 
regular  manner,  these  tubular  ducts  being  separated  by  connective 


ADENOCARCINOMA   OF  THE   STOMACH. 


529 


tissue,  which  generally  shows  small-celled  infiltration;  nor  are  these 
glandular  hollow  spaces  always  regular  in  distribution  or  in  size.  The 
order  of  the  lining  cell  is,  in  so  far,  a  typical  one,  as  the  whole  cavity  is 
filled  with  cells  of  which  only  the  outer  ones  are  cylindrical  and 


Fig.  36.— Cancerous  Invasion  of  the  Glandular  Layer.    A   Portion  of  the  Mucous 
Coat. — {From  the  Author'' s  Clinic.) 

Objective,  one-sixth.     Eyepiece,  one  inch.     X  about  320  diameters.     Stained  with  hematoxylin 

and  orange  G. 

This  cut  shows  very  well  the  small,  round-cell  infiltration  between  the  cross-sections  of  the 
gastric  tubules,  with  here  and  there  the  cells  very  much  crowded.  A,  A. 

The  exfoliation  of  the  cells  lining  some  of  the  glandular  acini  is  also  shown  in  places,  B. 

At  one  or  two  places  the  proliferation  of  the  epithelial  cells  that  line  the  glands,  witli  break- 
ing of  these  glandular  structures  and  the  escape  of  some  of  the  cells  into  the  surrounding  tissue, 
is  seen,  C,  C,  C. 

The  entire  obliteration  of  some  of  the  glandular  structures  by  masses  of  cancer  cells,  D,  D, 
which  in  many  places  are  strung  out  for  some  distance,  E,  E,  and  in  a  few  others  have  taken  on 
the  pseudo-glandular  arrangement,  F,  is  also  well  shown. 


arranged  in  regular  order,  while  the  rest  show  very  irregular  rela- 
tions, both  in  form  and  position.  The  cylindrical  cell  carcinoma  is 
most  frequently  found  in  the  pyloric  region,  its  favorite  place  being 
close  to  the  valve,  and  generally  sharply  limited  toward  the  duode- 


530 


MALIGNANT   TUMORS    OF    THE    STOMACH. 


num.  It  is  probable  that  the  neoplasm  originates  here  from  the 
pyloric  glands,  while  at  other  locations  of  the  stomach  the  surface 
epithelium  and  the  cylindrical  cells  of  the  gland  vestibules  form  the 
bases  of  origin.     The  papillary  forms  of  these  cancers  particularly 


^ 


C 


^ 


fl«^= 


'^^  £gi^y^:'--^fi^^4'^I  •  ••• 


.C 


c 


'     ^4^ 


Fig.  37. — Cancerous  Infiltration  of  the   Muscularis.    Section  of  a  Portion  of  the 
Muscular  Coat  of  the  Stomach.— (F7om  the  Author's  Clivic.) 

Objective,  one-sixth.     Eyepiece,   one   incli.     Stain,   liematoxyiin   and  orange  G.     X  about  320 

diameters. 

Cross-section  of  bundles  of  muscle-fibers  from  the  muscular  coat  are  shown.  A,  between  which 
there  are  a  large  number  of  small  round  cells,  B,  B,  in  places,  and  here  and  there  large  clumps 
of  cancer  cells,  C,  C,  C,  C,  a  few  of  which  show  the  attempt  at  pseudo-glandular  formation,  B,  £>, 
in  some  instances  arranging  themselves  in  complete  circles,  while  in  others  only  a  portion  of  an 
acinus  is  formed. 


have  a  tendency  to  grow  toward  the  surface,  for  they  may  last  a  long 
time;  i.  e.,  the  cancer  mass  may  assume  a  considerable  size  before  the 
infiltration  will  invade  the  outer  layers  of  the  stomach  wall.  The 
development  of  secondary  carcinomata  may  also  take  a  long  time,  so 


ADENOCARCINOMA    OF   THE    STOMACH. 


531 


that  with  very  large  malignant  neoplasms  perhaps  only  one  or  a  few 
lymph  glands  will  be  found  secondarily  involved.  Finally,  ulcera- 
tions of  the  surface  may  prolong  development ;  or,  if  a  loss  of  sub- 
stance does  occur,  it  may  be  compensated  for  by  proliferation  of  the 


Fig.  38.— a  Portion  of  an  Area  in  the  Submucosa,  Largely  Composed  of  Groups  of 
Cancer  Cells. — {From  Author's  Clinic.) 

Objective,  one-sixth.     Eyepiece,  one  inch.    Stained  with  hematoxylin  and  orange  G.     X  about 

320  diameters. 

The  fibrous  tissue  of  the  mucosa  is  infiltrated  with  many  small  round  cells,  which  in  some 
places  are  very  numerous,  A,  A.  The  most  prominent  change  appears  in  the  numerous  clumps 
of  cancer  cells,  most  all  of  which  lie  in  open  spaces  in  the  tissue,  B.  These  clumps  are  like  those 
seen  in  other  coats  of  the  stomach,  but  the  attempt  at  glandular  formation  is  more  marked  here 
than  inanv  other  locality,  C,  C.  In  the  upper  part  of  the  cut  is  seen  the  lower  portion  of  the  nius- 
cularis  mucosae,  D,  D,  infiltrated  with  many  small  round  cells,  and  containing  a  fewof  the  masses 
of  cancer  cells. 


tumor  tissue ;  eventually,  however,  with  the  co-operation  of  necrosis, 
a  larger  destruction  occurs.  The  ulceration  is  usually  surrounded  by 
a  projecting  fungus-like  wall. 

Occasionally  the  ensuing  necrosis — which  presumably  arises  from 


532 


MALIGNANT  TUMORS   OF  THK   STOMACH. 


disturbances  in  the  circulation — may  become  so  extensive  that  the 
entire  tumor,  with  the  exception  of  very  few  remnants,  may  be 
sloughed  off,  leaving  behind  an  ulcerating  base.  The  breakdown 
and  destruction  of  the  tumor  mass  frequently  progresses  in  a  gangren- 
ous manner,  and  then  we  may  find  not  only  formations  of  cavities 
within  the  tumor,  but  the  entire  stomach  walls  may  also  be  perfor- 


b    c       q, 


:s.SsoIz^:!::'ei; 


Fig.  39. — Section  of  Tissue  Near  the  Base  of  a  Carcinomatus  Ulcer,  Showing  Micro- 
organisms.— {From  Author's  Clinic.) 

Objective,  one-twelfth.     Eyepiece,  one  inch.     Stained  with  methyl-violet,  aniliii-oil  solution  by 
Gram's  method.     X  1060  diameters. 

a,  a,  a.  The  Oppler-Boas  bacillus,  singly  and  in  chains.  The  peculiar  base-ball  bat  shape  is 
shown  in  some  cases,  while  in  others  it  is  seen  that  one  end  of  the  rod  is  narrow  and  the  other 
broad,  the  change  in  size  being  sudden.  Some  of  the  rods  stain  solidly,  while  in  others  there  are 
clear  spaces. 

by  h,  b.  A  micrococcus  which  occurs  singly  and  in  clumps,  but  never  in  chains.  These,  as  well 
as  the  Oppler-Boas  bacillus  and  the  next  organism  to  be  described,  were  found  both  in  the  necrotic 
tissue  over  the  base  of  the  ulcer  and  in  the  healthy  tissue  below  the  same. 

c,  c,  c.  A  peculiar  yeast-like  organism,  that  is  probably  some  protozoan.  It  is  much  smaller 
'than  a  yeast  cell.  Budding  forms  are  seen,  and  the  granular  protoplasm  in  some,  and  the  few 
large  deeply  staining  dots  in  others,  are  well  represented. 


ated,  while  large  cancerous  proliferations  are  still  left  close  to  the  per- 
foration. 

The  second  main  type,  the  soft  glandular  or  'medullary  carcinoma, 
likewise  forms  knotty  projections  on  the  inner  surface  of  the  stomach, 
but  it  is  very  rare  that  these  are  observed  intact;  on  the  contrary, 
this  type  of  cancer  usually  appears  at  the  necropsy  as  a  cancerous 
ulceration.  Its  form  is  quite  characteristic.  It  presents  a  navel- 
like,  deepened  center  and  an  external  surrounding  wall  which  is 


GlyANDULAR   OR   MEDULLARY   CARCINOMATA.  533 

formed  by  the  mass  of  the  tumor ;  it  is  either  broad  or  narrow,  high  or 
low;  at  times  it  exhibits  a  uniform  appearance;  again,  it  is  irregu- 
larly ragged  in  outline.  In  the  bowl-shaped  central  depression  the 
tumor  mass  is  found  breaking  down  in  fragments,  or,  occasionally, 
this  depression  may  be  found  smooth,  since  the  more  resistant  muscu- 
laris  may  have  been  exposed  and  is,  presumably,  destroyed  much 
more  slowly  than  the  other  layers  by  the  action  of  the  gastric  juice. 
In  this  tumor  also  the  destruction  may  go  on  to  complete  perforation 
of  the  gastric  wall.  The  masses  of  the  tumor  which  surround  the 
ulceration  denote  more  or  less  extensive  retrogressive  metamorphoses, 
accompanied  by  hemorrhages,  and,  not  rarely,  an  ichorous  deteriora- 
tion of  the  tumor  mass.  On  microscopical  examination  of  these 
masses,  it  is  noticed  that  the  cancer  cells  are,  as  a  rule,  quite  small 
and  irregularly  shaped,  similar  to  oxyntic  cells,  but  that  their  num- 
bers far  exceed  the  stroma,  which  in  many  places  consists  chiefly  of 
very  thin,  delicate  partitions.  Larger  supporting  partitions  of  the 
stroma  exist,  of  course,  in  addition  to  these,  and  in  this  latter  type 
"small-celled  infiltration"  is  regularly  present.  Microscopical  ex- 
amination evinces  the  fact  that  the  soft  glandular  cancer  rapidly 
invades  the  exterior  gastric  layers,  for  small  nodules  (tumor  knots) 
appear  at  the  serosa  at  an  early  stage,  which  nodules  distinctly  show, 
and  correspond  to,  the  course  of  the  lymphatic  vessels.  These 
nodules  have  arisen  by  a  direct  advance  of  the  cancer  into  and 
through  the  muscular  layer,  in  which,  microscopically,  a  distinct 
thickening  is  observed,  this  thickening  being  dependent  upon  pro- 
liferation of  the  muscular  substance  itself,  as  well  as  upon  a  broaden- 
ing of  the  intermuscular  connective  septa.  (Fig.  37-)  Examining 
microscopically  a  section  through  the  muscularis,  it  at  once  becomes 
evident  that  the  cancer  masses,  in  their  invasions  between  the  muscu- 
lar fibers,  follow  the  septa  which  conduct  the  lymphatic  vessels.  In 
older  cases,  small  foci  are  found  in  the  muscle-bundles  themselves, 
where  they  have  forced  apart  the  muscle  cells  to  assume  the  shape  of 
pindle-like  spaces.  As  the  growth  of  the  carcinoma  is  much  more 
restricted  in  the  denser  and  closer  netted  muscularis  than  in  the  sub- 
serosa,  the  cancer  masses  outside  of  the  muscular  layer  are  generally 
considerably  more  voluminous  than  those  within  it.  The  (soft) 
medullary  carcinoma  may  extend  toward  the  surface  as  well  as  to- 
ward the  interior,  and  it  will  then  be  seen  that  it  habitually  follows 
preformed  passages — namely,  along  the  perilymphatic  spaces.  In 
very  rare  cases  this  neoplasm  may  extend  over  the  whole  stomach,  ex- 


534  MALIGNANT   TUMORS    OF    THE    STOMACH. 

cept,  possibly,  the  fundus ;  and  in  such  a  case  Orth  has  found  that  the 
entire  lymphatic  network  of  the  mucosa,  as  well  as  of  the  submucosa, 
was  filled  with  cancerous  masses.  The  greater  tendency  of  the 
medullary  carcinoma  for  local  dissemination  corresponds  to  its  rela- 
tions toward  the  general  organism.  With  this  neoplasm  particularfy, 
one  finds  extensive  lymphatic  gland  carcinomata,  not  only  in  the  epi- 
gastric, celiac,  portal,  and  retroperitoneal,  but  also  very  frequently  in 
the  left  supraclavicular  lymph-glands ;  one  may  find  metastases  in 
the  lymph-  as  well  as  in  the  blood-channels,  and,  besides,  a  dissemina- 
tion of  cancerous  nodules  in  the  abdominal  cavity. 

Concerning  the  seat  of  medullary  cancers,  it  may  be  said  that  they 
are  not  limited  to  any  particular  part  of  the  stomach,  for  they  may 
be  found  at  the  cardia,  the  anterior  and  posterior  walls,  and  the  lesser 
curvature  as  well  as  in  the  pyloric  region,  for  which  they  have  an  un- 
mistakable affinity.  Frequently,  cancers  of  the  cardia  extend  to  the 
esophagus,  while  the  duodenum  remains  intact. 

The  scirrhus  (meaning  hard  glandular)  is  distinguished  from  the 
two  preceding  types  of  carcinoma  mainly  by  its  hardness.  It  pro- 
duces no  large  tumor  nodules,  but  rather  simple  thickenings  of  the 
entire  wall.  The  surface  of  the  mucosa  shows,  as  a  rule,  a  flat  ulcera- 
tion, which  has  either  a  smooth  or  an  actually  cicatricial  basis,  or  else 
a  papillomatous,  irregular,  and  corroded  appearance.  The  edges  of 
the  ulcerations  are  generally  entirely  flat,  without  a  trace  of  the  wall- 
like elevation,  and  for  that  reason  the  transition  into  the  surrounding 
mucosa  is  very  gradual.  On  cutting  through  a  scirrhous  gastric  wall 
considerable  resistance  is  met  with,  so  that  the  tissue  actually  grates 
on  cutting.  Microscopical  section  reveals  a  thickening  of  all  layers, 
particularly  of  the  muscularis,  by  a  grayish-white,  striated,  cicatricial 
connective  tissue.  Typical  cancer  proliferation  is  not  apparent  on 
the  mucosa  nor  in  the  remaining  layers  of  the  gastric  wall,  so  that 
it  may  be  doubtful  whether  one  is  dealing  with  a  cancer  or  with  a 
simple  chronic  ulcer.  To  decide  this  question  one  must  observe  the 
relation  of  other  parts,  and,  particularly,  search  for  secondary  cancer 
formation. 

As  a  matter  of  fact,  one  occasionally  sees  small,  flat  tumor  nodules 
on  the  serosa  directly  over  the  neoplasm ;  but  as  extensive  adhesions 
of  the  pylorus  with  neighboring  organs- (liver,  intestine,  omentum)  are 
invariably  present  with  this  form  of  cancer,  implicating  the  perito- 
neum, such  nodules  are  difficult  to  recognize,  even  if  they  are  present. 
A  more  reliable  sign  is  the  condition  of  the  lymphatic  glands,  which 


SCIRRHOUS    CARCINOMATA.  535 

usually  show  cancer  formation;  and,  besides  this,  the  liver  and  other 
organs,  which  are  otherwise  rarely  invaded  (for  instance,  the  spinal 
column),  may  be  found  to  contain  it.  Such  cases  easily  give  rise  to 
deception,  because  these  secondary  tumors  may  show  a  medullary 
structure  and  attain  considerable  size,  in  which  case  the  seemingly 
unimportant  scirrhous  ulceration  in  the  stomach  may  be  overlooked. 
The  surest  indication  of  the  character  of  these  changes  is  obtained 
from  microscopical  examination,  though  in  a  section-preparation 
hardly  anything  else  but  fibrous  connective  tissue  is  seen,  particularly 
in  the  very  much  thickened  muscularis,  which  is  permeated  with 
broad,  grayish-white  stripes.  But  when  a  larger  number  of  prepara- 
tions are  carefully  examined  the  histological  peculiarities  of  carci- 
noma, the  connective-tissue  stroma,  and  carcinoma  bodies  are  dis- 
covered. 

The  last-named  are  diminutive  and  consist  of  small-celled  rows. 
The  stroma  is  massive,  and  composed  of  tough,  rigidly  fibered  con- 
nective tissue.  The  longitudinal  direction  of  the  small  cell-rows  is 
parallel  to  the  course  of  the  fibers  of  the  stroma.  It  is  noteworthy 
that  the  secondary  cancer  nodules  of  scirrhus  are  richer  in  cells,  and 
therefore  more  closely  resemble  the  medullary  carcinoma;  and  also 
that,  alongside  entirely  fibrous  places  in  the  gastric  wall,  here  and 
there  at  the  edges  of  the  ulcerations  places  can  be  found  where  the 
cancer  cells  are  not  as  yet  so  scarce  in  proportion  to  the  stroma,  and 
where  the  latter  does  not  as  yet  possess  the  characteristic  callous 
consistency.  It  may,  from  this,  be  concluded  that  the  scirrhus  is, 
in  fact;  an  atrophic  cancer  {cancer  atrophicans) — i.  e.,  that  the  callous 
— formation  represents  nothing  more  than  a  later  stage,  or  result,  of 
the  initial  cancerous  process.  The  question  has  arisen  whether  com- 
plete healing  may  not  be  produced  by  a  total  callous  metamorphosis 
of  the  neoplasm;  but,  up  to  the  present  time,  no  convincing  obser- 
vations confirmatory  of  this  question  have  been  made.  It  is  reasona- 
ble to  assume  that  a  very  localized  callous  cicatricial  healing  may  be 
brought  about  in  certain  places,  while  in  other  portions  (the  very 
youngest  parts  of  the  neoplasm)  very  slow  but  gradual  cancerous 
progress  is  made.  The  callous  stroma  of  the  scirrhus  has  a  tendency 
to  contract  such  formations. 

This  fact  is  of  great  significance,  when  the  microscopical  relation  of 
the  scirrhus  is  considered,  for  it  explains  the  stenosis  which  it  causes 
at  the  pylorus, — its  almost  exclusive  locality.  This  constriction  is 
further  increased  by  the  very  much  thickened  and  callus-like  altera- 


536  MAIvIGNANT  TUMORS   OP  THE;   STOMACH. 

tion  of  the  gastric  wall,  which  becomes  unresistant  and  inelastic,  re- 
sembling a  hard  rigid  ring,  or  stiff  tube.  It  is  self-evident  that  a 
pylorus  changed  in  this  manner  is  no  longer  capable  of  closing  off  the 
stomach  toward  the  duodenum  (incontinence  of  the  pylorus).  The 
extent  of  the  scirrhus  from  the  pylorus  toward  the  cardia  may  be 
variable,  rare  cases  occurring  in  which  the  entire  gastric  wall  is  in  a 
state  of  scirrhous  degeneration.  The  entire  organ  is  then,  as  a  rule, 
considerably  contracted,  and  at  the  same  time  the  walls  are  very 
much  thickened.  On  the  inner  surface  little  mucous  membrane 
remains  in  these  cases.  We  have  seen  elsewhere  that  a  similar  condi- 
tion may  be  brought  about  by  chronic  inflammation  (hyperplastic 
gastritis,  cirrhosis  of  the  stomach).  The  differential  diagnosis  is  verj" 
difficult  to  establish  from  the  local  conditions,  but  the  majority  of 
stomach  contractions  are  to  be  attributed  to  scirrhus  (Orth,  loc.  cit.). 
At  any  rate,  it  is  well  always  to  think  first  of  all  of  this  neoplasm. 

The  colloid  carcinoma  in  typical  cases  has  a  very  characteristic 
appearance.  It  does  not  produce  circumscribed  tumor  masses  so 
much  as  diffuse  thickenings  of  the  entire  wall  similar  to  scirrhus.  In 
this  growth  the  stroma  is  not  a  bright  fibrillar  tissue,  but  a  gelatinous, 
translucent,  colorless  or  light-brown  material.  These  masses  are 
recognizable  on  the  inner  surface,  which,  as  a  rule,  presents  an  ex- 
tended flat  ulceration.  Where  the  tumor  tissue  lies  exposed  there 
appears  a  distinct,  alveolar,  grayish  framework,  which  incloses  the 
colloid  granules,  in  dimension  the  size  of  a  pinhead  or  a  millet  seed. 
The  whole  mass  has  a  slimy,  mucoid  feeling,  but  it  is  not  nearly  so 
soft  as  genuine  mucus.  Microscopically  a  similar  picture  obtains; 
for  here,  also,  the  connective-tissue  alveolar  framework,  containing  a 
transparent  mucocolloid  mass  in  its  meshes,  is  prominent.  This  mass 
may  be  entirely  devoid  of  cellular  elements,  but  generally  a  number 
of  cells  and  cell  fragments  are  detected,  in  which  it  can  be  distinctly 
recognized  that  these  cells  themselves  furnish  the  colloid  material  of 
the  alveoli,  for  one  frequently  sees  many  cells  in  a  swollen  state,  either 
with  hyaline  granules  or  in  a  condition  of  disintegration.  In  other 
places  cells  may  be  found  in  better  preservation,  while  the  colloid 
matter  is  not  so  pronounced,  so  that,  in  this  form  of  carcinoma,  just 
as  in  scirrhus,  there  are  transitions  to  the  medullary  type.  Here, 
likewise,  the  youngest  portions  of  the  growth  are  those  most  rich  in 
cellular  elements,  and  production  of  colloid  material  is  a  phenomenon 
which  occurs  in  the  course  of  further  development  of  the  tumor. 

Colloid  tissue"  several  centimeters  thick  may  be  found  through- 


STRUCTURAI.  EFFECTS  OF  GASTRIC  CANCERS.        537 

out  the  entire  gastric  wall,  and  here  again  the  lymph-vessels  offer  the 
channels  in  which  the  cancerous  masses  take  their  course,  and  in 
which  they  ramify  both  interiorly  and  superficially.  Occasionally, 
larger  colloid  tumor  nodules  may  appear  on  the  serosa ;  and,  in  fact, 
the  colloid  carcinoma  not  rarely  invades  the  peritoneum  and  pro- 
duces an  extensive  carcinosis — as  a  result  of  which  the  omentum  is 
transformed  into  a  short,  thick,  and  board-like  band.  Affections  of 
the  lymphatic  glands,  liver,  lungs,  and  other  organs,  are  by  no  means 
absent.  The  colloid  carcinomata  also  have  their  favorite  location  in 
the  pyloric  region,  whence  they  may  extend  to  the  duodenum,  and 
also  to  the  liver,  by  direct  continuity.  The  extension  to  the  liver 
generally  occurs  after  the  formation  of  a  previous  adhesion.  A  transi- 
tion to  the  esophagus  from  the  cardia  has  likewise  been  observed. 
Although  the  colloid  carcinoma  produces  no  large  prominent  tumors, 
it  may  extend  far  over  the  gastric  surface,  and  frequently  takes  in  the 
entire  wall,  reducing  the  size  of  the  stomach  somewhat,  but  not  to 
such  a  degree  as  scirrhus.  The  wall  is  hard  and  immovable,  the  inner 
surface  ulcerated,  the  outer  coarsely  granular  from  small  and  large 
cancerous  nodules  of  the  peritoneal  covering. 

Although  the  ulcerations  of  the  colloid  carcinoma  may  have  consid- 
erable superficial  extent,  still  a  perforation  rarely  results,  although  the 
ulcerations  may,  at  places,  reach  even  to  the  peritoneum.  The  col- 
loid tissue  is  not  subject  to  rapid  disintegration,  hence  new  tumor 
masses  may  be  formed  in  front  of  the  basis  of  ulceration. 

Structural  Effects  of  Malignant  Gastric  Neoplasms. — The  de- 
velopment of  gastric  carcinoma  is  accompanied  by  adhesions  of  the 
serosa  with  the  pancreas,  liver,  the  transverse  colon,  the  anterior  ab- 
dominal wall,  and  the  omentum ;  and,  at  the  same  time,  there  occurs 
a  callous  hyperplasia  of  all  connective  tissue  in  the  immediate  neigh- 
borhood. The  result  is  that  the  stomach,  particularly  the  part  most 
frequently  affected  (namely,  the  pylorus),  becomes  fixed,  while  in 
other  rare  cases  such  adhesions  may  not  be  formed,  and  the  stomach 
is  dislocated  downward  by  the  tumor  masses,  in  which  case  the  p3do- 
rus  may  extend  as  far  as  the  symphysis  pubis.  Frequently  the  can- 
cerous stomach  exhibits  changes  of  size  and  form.  We  may  have 
diminutions  in  size  accompanying  the  total  degenerations  of  stenosing 
cardiac  carcinomata,  or,  what  is  more  common,  dilatation  accom- 
panied by  marked  muscular  hypertrophy.  The  dilatations  originate 
from  the  obstruction  of  the  passage  through  the  pylorus,  a  pyloric 
stenosis  existing.     This  may  be  caused  by  a  variety  of  circumstances. 


538  MAIvIGNANT   TUMORS    O^   THE    STOMACH. 

Among  the  causes  so  operating  may  be  mentioned,  in  the  first  place,  a 
large  tumor  mass  located  in  the  pyloric  orifice,  acting  like  a  cork  or 
ball-valve ;  secondly,  the  rigidity  which  the  walls  undergo  in  scirrhus 
and  in  colloid  carcinoma;  finally,  the  effective  contractions  of  the 
scirrhus,  whereby  a  considerable  resistance  is  offered  against  the 
advance  of  the  gastric  contents.  These  disturbances  may  be  in- 
creased by  a  large  variety  of  inflections  and  dislocations  resulting 
from  adhesions,  as  well  as  by  the  weight  of  the  accumulating  gastric 
contents.  Incontinence  of  the  pylorus  may  occur  contemporane- 
ously with  stenosis,  but  it  may  also  exist  in  a  very  severe  degree 
without  stenosis  where  the  cancerous  ulceration  has  destroyed  more 
or  less  of  the  pyloric  ring.  These  changes  at  the  pylorus  are  impor- 
tant because  they  are  very  frequent,  for,  as  is  evident  from  what  we 
have  said  concerning  the  various  types  of  carcinoma,  the  pyloric 
antrum  is  the  most  frequent  seat  of  cancer  formation.  According  to 
the  statistics  of  William  H.  Welch  ("A  System  of  Practical  Medicine 
by  American  Authors,"  edited  by  William  Pepper,  vol.  ii,  p.  561), 
the  frequency  of  carcinomata  occurring  at  the  pyloric  region  is  60.8 
per  cent. ;  at  the  lesser  curvature,  1 1.4  per  cent. ;  at  the  cardia,  8  per 
cent.;  at  the  posterior  wall,  5.2  per  cent.;  the  whole,  or  the  greater 
part  of  the  stomach,  4.7  per  cent.  According  to  Orth,  60  per  cent,  of 
all  gastric  cancers  invade  the  pylorus;  20  per  cent.,  the  lesser  curva- 
ture; 10  per  cent.,  the  cardia;  and  the  rest,  the  remaining  parts  of 
the  stomach.  As  gastric  carcinoma  makes  up  35  to  45  per  cent,  of  all 
carcinomata,  the  great  importance  of  pyloric  cancer  can  be  appre- 
ciated. In  the  midregions  of  the  stomach  the  cancers  are  limited 
to  a  portion  of  the  circumference,  but  in  the  vicinity  of  the  two  open- 
ings they  frequently  occupy  the  entire  circumference  in  a  ring-  or 
girdle-shaped  manner. 

The  growth  of  carcinomata  occurs  partly  through  simple  periph- 
eral extension,  partly  through  daughter  nodules  which  develop  at 
some  distance  from  the  main  tumor,  but  sooner  or  later  coalesce  with 
it.  These  nodules  evidently  lie  underneath  the  mucosa,  which  may 
be  movable  over  them ;  hence,  it  may  be  assumed  that  they  have 
arisen  through  infection  by  way  of  the  lymph-channels.  The  fre- 
quent occupation  of  lymphatic  vessels  b}^  cancer  masses  in  the  neigh- 
borhood of  larger  nodules  argues  in  favor  of  this  view.  Concerning 
the  secondary  infection  of  lymph-glands,  it  may  be  stated  that,  with 
gastric  carcinomata,  it  often  happens  that  glands  are  diseased  which 
do  not  receive  their  lymph  from  the  direction  of  the  stomach ;  for 


STRUCTURAL    EFFECTS    OF    GASTRIC    CANCER.  539 

instance,  the  retroperitoneal.  It  is  possible  that  this  is  caused  by  the 
cancerous  impermeability  of  glands  located  higher  up,  which  com- 
pels a  return  of  the  lymph-current.  Following  the  current  of  the 
lymph,  it  has  been  found,  by  Orth  and  others,  that  the  thoracic  duct 
may  be  infected.  Possibly,  the  infection  of  the  left  supraclavicular 
lymph-glands  occurs  in  connection  with  the  transportation  of  cancer- 
cells  through  the  lymph  of  the  thoracic  duct.  The  lymph-vessels  of 
the  diaphragm  may  be  entirely  filled  with  cancerous  masses,  and  may 
disseminate  the  elements  of  the  disease  to  the  pleural  cavity,  bron- 
chial glands,  and  lungs.  The  author  has  studied  sections  obtained  by 
operation  during  attempts  to  execute  a  Heinecke-Mikulicz  pyloro- 
plastic  operation  from  two  cases  of  what  proved  to  be  gastric  scirrhus 
later  on.  In  neither  case  did  microscopical  examination  reveal  any 
foci  of  cancer  cells;  a  large  number  of  sections  were  examined,  and 
the  appearance  was  that  of  a  chronic  hyperplastic  gastritis.  No- 
where could  any  small  cell  rows  of  cancer  bodies  be  discovered  in  the 
dense  connective-tissue  stroma.  Later  on,  metastases  developed, 
which  gave  evidence  of  the  malignant  nature  of  the  original  gastric 
induration.  This  experience  has  led  the  author  to  urge  gastro- 
enterostomy, or,  if  possible,  resection  in  all  doubtful  cases  of  chronic 
hyperplastic  gastritis.  If  it  should  happen  that  a  simple  benign  but 
hyperplastic  gastritis  is  treated  in  this  way,  the  patient  will  be  the 
gainer  by  the  operation,  for  this  form  of  gastritis  is  as  fatal  as  the 
malignant  types,  owing  to  the  absolute  rigidity  of  the  stomach  and 
loss  of  peristalsis  which  it  produces. 

In  twenty-five  per  cent,  of  all  gastric  cancers  secondary  nodules 
are  contained  in  the  liver.  The  infection  being  transported  by  direct 
extension  after  "adhesive  invasion,"  by  the  lymph -current  from  the 
porta  hepatica  or  transportation  by  the  blood-stream,  the  latter 
mode  being  by  far  the  more  plausible.  The  metastases  may  occur 
through  minute  particles  that  are  not  retained  emboli;  whereas, 
in  other  instances,  emboli  can  be  demonstrated  in  the  larger  vessels, 
proving  that  such  emboli  can  originate  from  the  stomach,  because  the 
gastric  veins  are  roots  of  the  portal  vein,  and  cancerous  invasion  of 
the  veins  of  the  stomach  is  conceded.  The  spreading  of  gastric 
cancer  to  the  esophagus,  duodenum,  spleen,  pancreas,  and  intestines 
occurs  by  direct  extension  along  the  paths  that  are  either  normally 
present  or  newly  formed  pathologically.  Participation  of  the  peri- 
toneum has  its  foundation  in  the  direct  extension  of  the  carcinoma 
into    the   gastric    serosa;    when,  however,   the    peritoneum  is  once 


540  MALIGNANT  TUMORS   OF   THE   STOMACH, 

invaded,  the  rest  of  it  is  not  affected  by  continued  simple  extension 
of  the  growth,  although  this  may  occur  with  colloid  carcinomata 
but  by  dissemination,  which  means  the  falling  of  tim^  particles  into 
the  peritoneal  cavity  (carcinoma  seed,  as  it  were)  and  their  attach- 
ment in  suitable  places  (at  first  in  the  deepest  portions  of  the  peri- 
toneum, in  the  rectovesical  and  rectouterine  pouch).  It  is  evident 
that  gravity  is  an  element  in  the  spreading  of  peritoneal  carcinoma. 
The  ulcerations  of  gastric  cancers  depend  partly  upon  ichorous  de- 
generation and  suppuration  and  partly  upon  the  digestive  influence 
of  the  gastric  juice,  which  occasionally  causes  perforation  of  the  stom- 
ach. The  vessels  of  the  stomach  and  of  the  spleen  may  be  affected 
by  an  inflammator}^  gangrenous  ulceration,  which  may  lead  to  dan- 
gerous hemorrhages,  but  these  cases  are  infrequent.  Cancerous 
ulcerations  are  vers^^  similar  to  the  simple  peptic  ulcer,  from  which 
they  may  be  distinguished  only  by  the  presence  of  the  tumor  wall, 
which,  if  absent,  enhances  the  difficulty  of  distinction  between  the 
two.  If,  indeed,  cancer  masses  are  found  in  the  surroundings  of  such 
an  ulceration,  the  questions  may  be  asked,  Has  the  ulceration  arisen 
from  a  carcinoma,  or  has  a  simple  gastric  ulcer  been  secondarily 
affected  by  cancer  transformation?  '  Here  the  clinical  history,  as  well 
as  the  examination  and  analysis  of  gastric  contents,  may  give  the  de- 
sired information.  Rosenheim  has  shown  that  normal  or  supernor- 
mal hydrochloric  acid  secretion  persists  in  the  carcinoma  which  has 
secondarily  developed  from  an  ulcer ;  but  when  the  carcinoma  is  the 
primar}^  growth,  the  hydrochloric  acid  is  permanently  absent  at  an 
early  stage  in  the  disease. 

Anatomically,  it  may  be  stated  that  when  the  ulceration  has  a 
regular  bowl-shaped  appearance,  and  is  on  every  side  surrounded  by 
tumor  masses,  even  where  no  cancer  masses  can  be  found  in  its  base, 
the  carcinomatous  tumor  undoubtedly  was  the  primary,  the  ulcera- 
tion the  secdonar\^,  object ;  and,  reversely,  when  a  simple  ulcer,  ac- 
companied by  all  typical  peculiarities,  presents  a  thickening  only  at 
one  side,  the  latter  tumor  mass  must  be  regarded  as  secondary  and  the 
ulcer  as  primary. 

In  a  very  interesting  monograph  relating  to  this  subject,  entitled 
"Ueber  die  Aetiologie  des  Carcinoms  "  (by  Gustav  Fiitterer,  Wies- 
baden, 1 901),  the  question  whether  a  genuine  gastric  ulcer  was  the 
primary  abnormality  and  the  carcinoma  the  secondary,  is  decided  in 
favor  of  the  peptic  ulcer  whenever  there  is  a  characteristic  forcing  up 
of   the  true   musclaris    toward   the    base    of   the   ulcer,  as  Hauser 


PRIMARY   DEVELOPMENT   OF   CANCER   FORMATION.  541 

has  described  it,  and  when  the  fish-hook  form  of  the  ulcer  is  present 
in  a  section  made  with  the  microtome,  perpendicular  to  the  surface 
of  the  ulcer.  This  fish-hook  form  has  been  depicted  by  me  in  the 
first  edition  of  this  book  (1897,  see  plate  viii,  facing  p.  478;  in  the 
second  edition,  facing  p.  506). 

The  remaining  gastric  mucous  membrane  sometimes  shows  insig- 
nificant alterations,  which  agrees  with  clinical  observations  as  to 
gastric  cancers  remaining  latent.  In  other  cases  a  pronounced 
chronic  inflammation  is  present,  particularly  in  the  immediate  vicin- 
ity of  the  tumor  masses  or  ulcerations.  A  hypertrophy  of  the  mus- 
culature is  frequently  apparent,  which  partly  depends  upon  altera- 
tions in  the  mucosa  and  partly  upon  a  pyloric  stenosis,  the  latter 
being  responsible  for  the  condition  of  the  gastric  contents,  because 
it  provokes  dilatation  and  its  consequences.  The  loss  of  secretion 
and  the  admixture  of  blood  with  the  gastric  contents  is  directly  trace- 
able to  the  cancerous  infiltration  or  the  accompanying  gastritis,  or 
both.  The  hemorrhages  may  arise  by  ulcerative  disintegration,  as 
well  as  from  rupture  of  the  small  vessels  in  the  villous  cancer  pro- 
liferations. 

What  is  the  source  or  basis  of  the  primary  development  of  cancer 
formation?  According  to  prevalent  views,  all  gastric  carcinomata 
do  not  originate  from  the  connective  tissue  of  the  submucosa,  as  was 
formerly  believed,  but  from  the  mucosa,  and  particularly  from  the 
glandular,  or  surface,  epithelium  of  the  same,  the  cells  of  these  car- 
cinomata having  great  similarity  to  the  various  cells  of  the  mucosa. 
All  gastric  carcinomata  are  therefore  epithelial  tumors.  We  owe  to 
Waldeyer  the  first  exact  investigations  concerning  the  beginning  of 
cancer  formation,  which  have  been  confirmed  later  by  other  re- 
searches. According  to  him,  the  process  begins  with  an  enlargement 
and  hypertrophy  of  a  group  of  ten  or  twelve  glands,  which,  breaking 
through  the  muscularis  mucosae,  enter  the  submucosa.  The  cells  of 
these  gland-ducts  react  differently  to  staining  reagents,  being  colored 
much  deeper,  and  filling  the  lumen  of  the  gland  in  an  irregular  man- 
ner. A  further  step  is  that  the  connective  tissue  of  the  mucosa,  and 
particularly  of  the  submucosa,  undergoing  a  transformation  into 
granulation  tissue,  advances  and  is  pushed  up  against  the  aggrega- 
tions of  epithelial  cells,  which  are  thus  forced  apart  and  inclosed  in 
groups  by  the  connective  tissue,  giving  rise  to  the  cancer  alveoli  and 
cancer  bodies  (cancer  cells).  Accepting  this  as  a  general  rule,  the 
question  arises,   What  causes  this  gland  group  and  the  adjoining 


542  MALIGNANT   TUMORS    OF   THE    STOMACH. 

connective  tissue  to  enter  upon  this  abnormal  growth?  Cohnheim 
says  that  abnormal  conditions  of  primitive  germinal  tissue  are  pres- 
ent here,  a  remnant  of  unused  primitive  cells  from  which  the  prolifer- 
ation starts.  This  is  a  hypothesis  which  can  admit  of  no  proof,  since 
after  the  proliferation  has  occurred  it  is  impossible  to  obtain  any 
knowledge  of  the  condition  of  the  locality  that  existed  there  prior  to 
the  proliferation.  But  even  admitting  Cohnheim's  theory,  we  must 
ask,  Why  do  these  embryonic  cells  suddenly  begin  to  grow  after  many 
years  ?     There  must  evidently  be  some  other  incentives  to  growth. 

There  is  undoubtedly  some  disposition  toward  the  development  of 
gastric  cancers  with  advancing  age.  What  the  nature  of  this  predis- 
position is  we  do  not  know.  There  seems  to  be  no  predisposition  of 
sex,  for  both  sexes  are  attacked  with  equal  frequency.  The  pro- 
nounced tendency  which  the  structures  of  the  pylorus  exhibit  toward 
cancerous  infection  attracts  attention  to  the  mechanical  relations 
there  existing.  Hauser  has  made  some  interesting  observations  on 
the  development  of  cancers  from  simple  peptic  ulcers.  He  has  shown 
that  the  gastric  secretory  glands  at  the  edges  of  healing  ulcers  undergo 
a  proliferation  which  may  be  augmented  to  a  cancerous  neoplasm, 
and  he  seeks  the  explanation  for  this  process  in  an  increased  supply 
of  nutritive  material  to  the  glands,  and  in  a  reduction  of  the  resistance 
of  the  adjoining  tissues  in  consequence  of  an  ulcerative  and  cicatricial 
process. 

As  frequent  as  primary  carcinomata  are,  just  so  rare  are  the  sec- 
ondary. Secondary  cancers  may  arise  in  the  stomach  by  direct  ex- 
tension from  the  immediate  surroundings.  In  this  manner  a  cancer 
might  extend  to  the  gastric  walls  from  the  pancreas,  liver,  and  lymph- 
atic glands.  Clinically,  the  most  important  of  the  primary  carcino- 
mata is  the  esophageal,  which,  when  it  is  located  at  the  cardia,  may 
invade  the  stomach.  Reversely,  the  extension  of  gastric  cancer  into 
the  esophagus  is  really  more  frequent.  There  is  another  kind  of  ex- 
tension of  esophageal,  lingual,  and  facial  carcinomata  to  the  stomach, 
which  is  not  transmitted  by  the  lymph-  or  blood-channels,  but  by  a 
direct  implantation  of  cancer  cells  upon  the  mucosa.  Klebs  was  the 
first  to  report  three  of  such  cases,  and  Beck  has  investigated  a  case, 
concerning  which  he  assumes,  on  the  strength  of  his  microscopical 
preparations,  that  the  loosened  parts  of  the  esophageal  cancer  had 
fastened  themselves  in  the  gastric  glands.  The  new  nodules  which 
were  thus  formed  were  flattened  epithelium  carcinomata,  composed 
of  the  typical  pavement-epithelium  of  the  esophagus.     This  raises 


THEORY   OF    INFECTIOUS    ORIGIN    OF    CANCER.  543 

the  interesting  question  whether  the  new  tumors  arise  solely  and  ex- 
clusively from  the  implanted  tumor  cells,  or  whether  these  cells  pro- 
duce a  kind  of  infection  of  the  local  cells  upon  which  they  fall,  so 
that  the  latter  are  converted  into  pavement-epithelium  cancer  cells. 
Klebs  assumes  the  latter  view,  but  Beck  leaves  the  question  unde- 
cided. In  the  place  occupied  by  the  tumor  that  he  investigated,  no 
gastric  cells  were  observable,  and  also  no  transition  forms  to  pave- 
ment cells.  The  secondary  cancers  of  the  peritoneum,  already  de- 
scribed, arise  in  a  similar  manner — namely,  by  the  falling  of  cancer 
particles  into  the  peritoneal  cavity.  Reversely,  it  has  been  observed 
that  an  implantation  carcinoma  may  arise  upon  the  gastric  serosa 
from  a  deeper  portion  of  the  abdominal  cavity.  Orth  describes  a 
case  in  which  the  inner  mucous  membrane  of  the  pylorus  showed  a 
typical  cylindrical  cell  carcinoma,  while  the  serosa  of  the  same  viscus 
revealed  a  pronounced  colloid  nodule  as  large  as  a  walnut,  which 
could  not  have  arisen  in  any  other  way  except  by  implantation  from 
a  colloid  carcinoma  of  the  cecum.  Another  mode  of  secondary  cancer 
formation  is  that  of  metastasis  by  way  of  the  blood-vessels,  these 
secondar)'^  neoplasms  corresponding  to  the  primary  tumors  in  struc- 
ture, and  being  recognizable,  according  to  Grawitz,  as  secondary  by 
their  circumscribed  character.     These  secondary  forms  are  rare. 

The  theory  of  infection  for  the  origin  of  gastric  cancers  would  not 
explain  the  great  variety  of  the  histogenesis  of  the  carcinoma.  In 
accepting  the  existence  of  a  "cancer-producing  microbe,"  one  would 
have  to  assume  that  this  organism  could  produce  a  transformation 
of  connective  tissue  into  epithelium,  or  that  it  regularly  produced 
proliferation  only  in  one  kind  of  tissue — namely,  the  epithelial.  A 
pathogenic  micro-organism  with  these  qualities  is  unknown  at  the 
present  time.  In  the  formation  of  metastases  only  the  transported 
cancer  cells  keep  on  proliferating  in  the  new  organ,  while  the  tissue  of 
this  organ  either  does  not  participate  at  all,  or  only  to  a  small  degree, 
in  the  formation  of  the  new  cancer  nodule.  In  the  transportation 
of  tuberculous  tissue,  however,  it  is  this  tissue  which  breaks  down, 
and  the  new  tuberculous  focus  develops  from  the  invasion  of  the 
transported  tubercle  bacilli,  which  not  only  cause  a  disease  of  the  epi- 
thelium, but  also  of  the  remaining  tissues  (connective  tissue,  bone, 
etc.)  with  which  they  come  in  contact.  Transplantation  of  carcinoma 
into  animals  has  very  rarely  succeeded,  whereas  inoculations  of  in- 
fectious diseases  are  generally  successful.  Another  explanation  of 
the  development  of  cancer  has  been  attempted  in  the  so-called  "irri- 
36 


544  MAI.IGNANT   TUMORS    OF   THE;   STOMACH. 

tation  theory,"  which  is  based  upon  the  susceptibility  of  the  two 
openings  of  the  stomach  to  greater  irritation  during  digestion  than 
other  parts ;  these  portions  are  consequently  most  frequently  affected 
(sixty  to  seventy  per  cent,  of  all  cases) ;  but  satisfactory  proof  that 
this  irritation  may  cause  cancer  per  se  is  wanting.  We  have  else- 
where stated  the  percentage  of  cancers  occurring  at  various  decades 
of  life:  According  to  the  statistics  of  Welch,  Brinton,  and  Lebert, 
three-fourths  of  all  cancers  occur  from  the  fortieth  to  the  seventieth 
year,  and  from  the  thirtieth  to  the  seventieth  3^ear  ninety-five  per 
cent,  of  all  gastric  cancers  manifest  themselves.  So  far  as  we  know, 
only  one  case  of  congenital  cancer  that  was  limited  to  the  stomach  has 
been  reported  (Wilkinson).  There  has  been  one  case  of  congenital 
cancer  combined  with  carcinoma  of  other  organs  ( Widerhof er) .  We 
found  in  the  literature  on  this  subject  a  case  of  gastric  cancer  in  a 
child  five  weeks  old  (Culling worth).  Three  other  cases  in  children 
somewhat  older  are  reported  by  Scheffer.  (The  subject  of  the  etiol- 
ogy of  cancer  is  reviewed  in  an  interesting  article  by  Roswell  Park, 
"N.  Y  Med.  Record,"  vol.  ui,  No.  i,  July  3,  1897.) 

Heredity. — It  is  generally  accepted  that  the  predisposition  to  can- 
cer may  be  inherited.  According. to  Fleischer,  the  life  insurance 
companies  in  Germany  have  increased  their  premiums  for  candidates 
in  whose  families  gastric  carcinoma  has  been  observed.  Napoleon  I, 
his  sister,  and  his  father  died  of  gastric  carcinoma. 

Geographical  Distribution. — The  geographical  distribution  of  gas- 
tric cancer  is  very  irregular,  for  while  it  is  very  rare  in  some  countries, 
— as  in  Turkey,  Egypt,  and  the  tropics, — it  is  said  to  be  very  frequent 
in  Thiiringen,  in  Suabia,  in  Normandy,  and  in  Switzerland.  The 
causes  of  this  unequal  distribution  are  unknown.  In  Egypt  gastric 
cancers  are  unknown  (Griesinger),  but  gastritis  and  enteritis  are  of 
common  occurrence.  This  seems  to  show  that  a  gastric  relation 
between  gastritis,  enteritis,  and  carcinoma  does  not  exist.  Accord- 
ing to  Eichhorst  and  Haeberlin,  two  per  cent,  of  all  deaths  in  Switzer- 
land are  caused  by  gastric  cancer.  From  mortuary  statistics,  Tan- 
chou  ("Rech.  sur  le  Traitement  Med.  des  Tumeurs  du  Sein,"  Paris, 
1824)  estimates  the  frequency  of  gastric  cancer  as  compared  with  that 
of  all  the  causes  of  death  at  0.6  per  cent.  ;*  Virchow,  at  1.9  per  cent. ; 
Wyss,  at  2  per  cent. ;  and  D'Espine,  at  2^  per  cent.  In  8468  autop- 
sies, chiefly  from  English  hospitals,  Brinton  found  gastric  cancer  re- 

*  Tanchou's  statistics  are  based  upon  an  analysis  of  382,851  deaths  in  the  Department 

of  the  Seine  (see  Welch,  loc.  ciL,  p.  532). 


RELATION    OF   AGE    AND    GASTRIC    CANCER. 


545 


corded  in  i  per  cent,  of  the  cases.  Gussenbauer  and  von  Winni- 
warter  found  gastric  cancer  recorded  in  i^  per  cent,  of  the  61,287 
autopsies  in  the  Pathological  Anatomical  Institute  of  the  Vienna 
University.  From  an  analysis  of  11,175  autopsies  in  Prague,  Welch 
found  gastric  cancer  in  3^  per  cent,  of  the  cases. 

Welch  has  collected  and  analyzed,  with  reference  to  this  point,  the 
statistics  of  death  from  all  causes  in  the  city  of  New  York  for  the 
fifteen  years  from  1868  to  1882  inclusive,  and  reported  that  of  444,564 
deaths  during  this  period,  cancer  of  the  stomach  was  assigned  as  the 
cause  in  1548  cases,  and  cancer  of  the  liver  in  867  cases.  Some,  at 
least,  of  these  so-called  cancers  of  the  liver  may  be  reckoned  gastric 
cancers.  This  would  make  the  ratio  of  gastric  cancer  to  all  causes  of 
death  about  0.4  per  cent.,  and  nearly  i  per  cent.  (0.93  per  cent.)  if 
only  the  deaths  from  twenty  years  of  age  upward  be  taken,  gastric 
cancer  hardly  ever  occurring  under  that  age.  It  is  a  fair  presump- 
tion, also,  that  in  New  York  not  over  i  in  200  of  the  deaths  occurring 
— at  all  ages  and  from  all  causes — is  due  to  cancer  of  the  stomach,  and 
that  about  i  in  100  of  the  deaths  from  twenty  years  of  age  upward  is 
due  to  this  cause. 

The  following  table  (by  William  H.  Welch,  loc.  oil.)  gives  the  age 
in  2038  cases  of  gastric  cancer,  obtained  from  trustworthy  sources 
and  arranged  according  to  decades : 


Age,  .... 

10-20 

20-30 

30-40 

40-50 

50-60 

60-70 

70-80 

80-90 

90-100 

Over 
100 

No.  of  Cases, 

2 

55 

271 

499 

620 

428 

140 

20 

2 

I 

Per  cent., 

O.I 

2.7 

133 

24-5 

30-4 

21 

6.85 

I 

0.1 

0.05 

From  this  analysis  we  may  conclude  that  three-fourths  of  all  gastric 
cancers  occur  between  forty  and  seventy  years.  The  absolutely 
largest  number  is  found  between  fifty  and  sixty  years;  but,  taking 
into  consideration  the  number  of  those  living,  the  liability  to  gastric 
cancer  is  as  great  between  sixty  and  seventy  years.  Nevertheless, 
the  number  of  cases  between  thirty  and  forty  years  is  considerable, 
and  the  occurrence  of  gastric  cancer  even  between  twenty  and  thirty 
is  not  so  exceptional  as  is  often  represented,  and  is  by  no  means  to  be 
ignored.  The  liability  to  gastric  cancer  seems  to  lessen  after  seventy 
years  of  age,  but  here  the  number  of  cases  and  the  number  of  those 
living  are  so  small  that  it  is  hazardous  to  draw  positive  conclusions. 


546 


MALIGNANT   TUMORS    OF   THE)    STOMACH. 


Location. — The  following  table  gives  the  situation  of  the  tumor  in 
1300  cases  of  stomach  cancer  (from  article  by  Wm.  H.  Welch,  loc.  cit.) : 


Pyloric 
Region. 

Lesser 
Curva- 
ture. 

Cardia. 

Pos- 
terior 
Wall. 

Whole  or 
Greater 
Part  of 

Stomach. 

Mul- 
tiple 
Tumors. 

Greater 
Curva- 
ture. 

An- 
terior 
Wall. 

Fundus. 

791 

60.8 
per  cent. 

148 

II. 4 
per  cent. 

104 

8 
per  cent. 

68 

5-2 
per  cent. 

61 

4-7 
per  cent. 

45 

3-5 
per  cent. 

34 

2.6 
per  cent. 

30 

2.3 
per  cent. 

19 

1-5 
per  cent. 

From  this  table  it  appears  that  three-fifths  of  all  gastric  cancers 
occupy  the  pyloric  region ;  but  it  is  not  to  be  understood  that  in  all  of 
these  cases  the  pylorus  itself  is  involved.  In  four-fifths  of  the  cases 
the  comparatively  small  segment  of  the  stomach  represented  by  the 
cardia,  the  lesser  curvature,  and  the  pyloric  region,  is  the  part  affected 
by  gastric  cancer.  The  lesser  curvature  and  the  anterior  and  posterior 
walls  are  involved  more  frequently  than  appears  from  the  table,  inas- 
much as  many  cancers  assigned  to  the  pyloric  regions  extend  to  these 
parts.  The  fundus  is  the  least  frequent  seat  of  cancer.  In  the  cases 
classified  as  involving  the  greater  part  of  the  stomach  the  fundus  often 
escapes. 

Frequency. — Malignant  disease  is  on  the  increase  in  this  country. 
The  death-rate  from  cancer  in  New  York  city  was  1.82  per  cent,  from 
1874  to  1884,  but  from  1884  to  1894  the  death-rate  from  cancer  was 
2.17  per  cent,  of  the  total  mortality  (Jos.  D.  Bryant,  the  "Wesley  M. 
Carpenter  Lecture,"  "New  York  Med.  Journal,"  May  18,  1895). 
Haeberlin  ("Deutsches  Archiv  f.  klin.  Med.,"  1889,  Heft,  iii  und  iv) 
gives  the  percentage  of  cancer  of  the  stomach  from  1877  to  1886  as 
4.1  per  cent.  This  writer  has  called  attention  to  the  fact  that  in 
Switzerland  also  gastric  cancer  is  on  the  increase ;  his  figures,  showing 
the  death-rate  from  cancer  of  the  stomach  for  1000  inhabitants,  are 
the  following:  1877,  0.61  per  cent.;  1878,  0.66  per  cent.;  1879,  0.72 
per  cent.;  1880,  0.77  per  cent.;  1881,  0.85  per  cent.;  1882,  0.87  per 
cent.;  1883,  0.85  per  cent. ;  1884,  0.84  per  cent. ;  1885,  0.90  per  cent. ; 
1886,  0.99  per  cent.  In  England  the  proportion  of  deaths  from  can- 
cer to  the  total  mortality  rate  was  i  in  129  in  1840.  This  had  risen 
to  I  in  28  in  1880.  The  death-rate  from  cancer  is  now  about  four 
times  as  great  in  England  as  it  was  fifty  years  ago.  The  published 
figures  of  the  Registrar-General's  report  indicate  that  the  mortality 
from  cancer  in  the  years  from  1870  to  1890  has  increased  53  per  cent. 


SARCOMA   OF    THE    STOMACH.  547 

in  England.  These  facts  are  alarming  and  should  stimulate  the  most 
diligent  search  for  the  cause  of  this  disease.  (For  more  complete 
statistics  from  various  States  and  cities  in  this  country  see  J.  C.  Hem- 
meter,  "New  York  Med.  Record,"  Oct.  21,  1899,  p.  577.) 

(B)  SARCOMATA. 

The  sarcomata  of  the  stomach  are  also  classified  into  two  groups 
according  to  their  origin — namely,  primary  and  secondary.  The 
latter  are  by  far  the  more  rare.  A  single  exception  to  this  rule  is  the 
lymphosarcoma.  The  primary  sarcoma  of  the  gastric  wall  may  de- 
velop from  any  place  within  the  organ,  but  the  greater  curvature 
seems  to  be  preferred,  at  least  by  such  development  as  that  in  which 
tumor  nodules  (myosarcoma  and  fibrosarcoma)  are  formed,  and  in 
which  no  extensive  lateral  infiltrations  are  met  with. 

There  is  a  disposition  on  the  part  of  some  authors  (H.  Schlesinger, 
"Zeitschrift  f.  klin.  Med.,"  Bd.  xxxii,  Supplement-Heft,  S.  179)  to 
separate  the  lymphosarcomata,  on  account  of  their  different  anatomi- 
cal relations,  from  the  other  sarcomata.  The  point  of  issue  of  the 
latter  group  is  either  the  muscularis  or  the  submucosa,  the  mucosa  not 
being  diseased  primarily.  It  may,  however,  become  injured  in  the 
further  progress  by  the  arching  forward  of  the  tumor  toward  the 
interior  of  the  stomach,  resulting  in  lesions  of  the  mucosa ;  in  a  purely 
mechanical  way,  from  pulling  and  stretching;  or  it  may  become 
ulcerated  toward  the  inner  gastric  cavity.  In  some  cases  the  tumor 
may  arch  toward  the  peritoneal  cavity.  In  the  center  of  the  sarco- 
matous nodules,  particularly  in  the  center  of  myosarcomata,  processes 
of  softening  and  disintegration,  even  of  a  purulent  nature,  may  occur 
and  give  rise  to  septic  peritonitis.  These  tumors  possess  a  spherical 
or  an  irregularly  knotty  form,  and  are  attached  by  either  a  broad  or 
narrow  basis;  they  sometimes  attain  vast  dimensions  (Brodowski 
described  a  myosarcoma  weighing  twelve  pounds).  Metastases  in 
neighboring  organs,  particularly  in  the  lymphatic  glands,  greatly 
modify  the  anatomical  picture,  duplicating,  as  to  appearances,  the 
original  tumor.  The  tumors  that  have  been  observed  so  far  are: 
Spindle-celled  sarcoma  (Hardy,  Weissblum,  Habershon,  Tilger, 
Malvoz) ;  angiosarcoma  (Bruch) ;  myosarcoma  (Virchow,  Kosinski, 
Kolisko,  Brodowski);  and  fibrosarcoma  (Tilger,  Kwald,  Dreyer). 
The  majority  of  the  round-celled  sarcomata  that  have  been  described 
(Virchow,  Cayley,  hegg,  Berry,  vShaw,  Drost,  Rasch)  are  properly 
classed   with   the   lymphosarcomata.     W.    Fleiner   ("Lehrbuch   der 


548  MALIGNANT   TUMORS    OF   THB    STOMACH. 

Krankheiten  der  Verdauungsorgane, "  Theil  i,  vide  Magensarcom,  S. 
295  und  311)  has  clinically  observed  one  case  of  lymphosarcoma  and 
one  case  of  round-celled  sarcoma,  and  made  histological  studies  of 
the  same  from  the  autopsies ;  and  H.  Schlesinger  has  given  the  clinical 
history  and  undertaken  the  histological  study  of  two  cases  of  lympho- 
sarcoma and  one  of  round-celled  sarcoma  of  the  stomach  {loc.  cit.). 

The  primary  lymphosarcomata  of  the  stomach  seem  to  be  rarer 
than  the  secondary  form.  In  some  cases  the  infiltration  is  limited 
mostly  to  the  pyloric  region,  causing  a  rigid  thickening  of  this  part 
(Torok).  In  other  cases  it  occurs  in  enormous  infiltrations  extending 
over  the  whole  stomach,  giving  to  the  inner  surface  the  appearance  of 
a  coarse  swelling;  it  may  also  have  the  appearance  of  a  uniform  infil- 
tration. The  mucous  membrane  may  be  preserved  for  a  long  time  in 
lymphosarcomata,  but  ulceration  is  not  impossible.  The  spreading 
of  the  disease,  as  is  usual  with  a  lymphosarcoma,  occurs  by  the  lymph- 
atic channels,  those  lymphatic  glands  that  are  nearest  becoming 
diseased  first,  then  the  adjacent  organs,  and,  lastly,  the  peritoneum. 
Sometimes  no  metastases  occur,  as  in  one  case  of  Fleiner's;  more 
frequently  lymphosarcomata  are  found  as  secondary  neoplasms  in 
the  stomach  after  primary  tumors  in  other  organs.  In  the  cases  of 
Kundrat  ("Ueber  Lymphosarcomatose, "  "Wien.  klin.  Wochen- 
schr.,"  1893,  No.  12)  the  original  infected  areas  were  the  neck, 
phar^^nx,  gums,  and  even  the  rectum. 

Symptomatology. — What  is  said  here  on  symptomatology  has 
reference  to  all  neoplasms  of  the  stomach.  In  a  small  number  of 
cases  the  development  of  malignant  growth  of  the  stomach  remains 
entirely  latent,  because  every  typical  gastric  symptom  is  wanting 
until  death.*  As  far  as  we  have  had  occasion  to  observe,  the  first 
symptoms  of  a  gastric  carcinoma  are  those  of  chronic  gastritis. 

Most  of  these  patients  state  that,  up  to  the  time  of  their  disease, 
they  enjoyed  a  very  good,  sound  stomach.  The  first  dyspeptic  com- 
plaints are  those  of  pressure  and  fullness  in  the  gastric  region,  eructa- 
tions, anorexia,  nausea,  vomiting,  cardialgia,  and  coated  tongue. 
Disturbances  of  sensibility  are  not  felt  until  the  neoplasm  has  reached 
a  certain  size,  thereby  exerting  pressure  on  the  sensory  nerves  of  the 
stomach ;  or  when,  by  its  ulcerations,  or  by  the  irritation  of  the  diges- 
tive juices,  these  nerves  have  been  exposed.     The  patient  has  a  sensa- 

*  Friedenwald  and  Hotaling,  "  N.  Y.  Med.  Rec,"  Sept.  24,  1898,  have  collected 
the  literature  of  a  large  number  of  such  cases.  Osier,  "  Principles  and  Practice  of 
Med.,"  refers  to  several  that  were  observed  at  the  Johns  Hopkins  Hospital. 


SYMPTOMATOLOGY    OF    GASTRIC    SARCOMA.  549 

tion  as  if  a  stone  were  lying  in  his  stomach,  sometimes  complaining 
of  unpleaseant  feelings  of  emptiness,  which  come  both  at  a  varying 
time  after  eating  as  well  as  on  an  empty  stomach,  and  not  rarely 
continue  an  entire  day,  so  that  the  patient  is  constantly  reminded  of 
his  stomach,  which  he  was  not  aware  of  formerly,  and  is  placed  in 
that  characteristic  despondent  and  melancholic  mood  frequently  met 
with  in  gastric  sufferers.  These  sensations  may  increase  to  actual 
pain,  which,  however,  is  not  so  severe  as  in  ulcer.  Eructations  are 
present  in  the  beginning  of  gastric  ulcer  as  well  as  later  on,  either 
bringing  up  air  or  small  particles  of  the  gastric  contents,  which  have  a 
bitter  taste ;  but,  later  on,  when,  in  consequence  of  achylia,  the  stag- 
nating gastric  ingesta  ferment  more  and  more,  the  eructated  gas  may 
have  a  disgusting,  decomposed  odor  and  taste. 

Pyrosis  may  be  present,  and  is,  as  a  rule,  accompanied  by  excess  of 
organic  acids.  Singultus  occasionally  accompanies  the  eructations, 
and  is  observed  most  frequently  with  carcinoma  of  the  cardia.  In 
rare  cases  (Ebstein  and  Eichhorst)  there  may  be  a  tetany  of  the  con- 
strictor muscles  of  the  pharynx,  which  is  said  to  be  caused  reflexly 
from  the  stomach,  and  may  prevent  ingestion  of  food.  The  frequency 
of  nausea  and  vomiting  depends  upon  the  location  of  the  tumor  in  the 
stomach ;  they  are  never  absent  when  the  neoplasm  is  located  at  the 
cardia  or  pylorus.  The  nature  and  chemical  condition  of  the  vom- 
ited matter  depend  upon  the  time  of  the  emesis  and  the  degree  of 
secretory  disturbance  as  well  as  upon  the  extent  of  the  gastritis,  and 
may  consist  of  more  or  less  altered  ingesta,  decomposed  food  rem- 
nants, mucus,  blood,  or  bile.  Advanced  decomposition  is  not  ob- 
served until  a  late  period  of  the  growth.  The  vomited  masses  are 
rich  in  bacteria,  and  contain  the  Oppler-Boas  bacilli,  which  are  char- 
acteristic of  lactic  acid  fermentation,  though  not  pathognomonic  of 
cancer  (p.  131).  The  tongue  nearly  always  has  a  brownish -yellow  or 
grayish-white  coating,  but  may  be  quite  clean  after  profuse  vomiting. 
The  taste  is  said  to  be  pasty,  bitter,  or  offensive  in  the  last  stages,  and 
salivation  and  thirst  are  increased.  The  loss  of  appetite  belongs  to 
the  earliest  symptoms,  with  particular  dislike  for  meat  at  all  stages  of 
the  disease.  In  some  patients  complete  anorexia  alternates  with 
bulimia.  As  a  rule,  appetite  remains  fair  as  long  as  there  is  any  gas- 
tric secretion,  or  as  long  as  the  motility  remains  fairly  good. 

Thirst  is  an  annoying  symptom  in  pyloric  cancers,  because  they 
prevent  the  passage  of  water  into  the  intestines — the  stomach  being 
incapable  of  absorbing  water. 


550  MAIylGNANT   TUMORS    OF    THE    STOMACH. 

Constipation  and  Diarrhea. — In  the  literature  in  which  any  refer- 
ence to  these  points  was  made,  I  found  that  in  75  per  cent,  of  gastric 
cancers  there  is  constipation,  in  20  per  cent,  there  is  diarrhea,  and 
only  in  5  per  cent,  does  the  stool  remain  normal.  The  greater  fre- 
quency of  constipation  is  due  to  mechanical  stenosis  by  tumor  or  to 
motor  insufficiency  due  to  carcinomatous  invasion  of  the  muscularis. 

Disturbance  of  Peristalsis,  Secretion,  and  Absorption. — These  are 
caused  by  chronic  gastritis,  anemia,  or  direct  extension  of  the  neo- 
plasm into  the  mucosa  and  muscularis  of  the  stomach.  The  dis- 
turbances of  motility  are  either  due  to  destruction  of  the  muscularis 
or  invasion  of  the  gastric  neoplasm,  or  to  stenosis  at  the  pylorus. 
We  do  not  believe  that  they  are  traceable  solely  to  the  induced  gas- 
tritis, because  in  chronic  gastritis,  according  to  very  careful  observa- 
tions, the  motility  in  the  majority  of  cases  is  not  very  seriously  inter- 
fered with.  Accordingly,  we  find  that  in  from  three  to  four  hours 
after  the  test-breakfast,  or  eight  to  ten  hours  after  a  full  test-dinner, 
when  the  stomach  normally  should  be  empty,  an  abundance  of  food 
remnants  is  contained  in  it.  In  cases  where  the  neoplasm  is  not 
located  at  either  orifice  of  the  stomach,  the  motility  remains  good  for 
a  long  time,  and  even  in  the  absence  of  secretion  of  HCl,  the  vicarious 
digestion  of  the  intestines  is  sufficient  to  make  up  for  the  loss  of  gas- 
tric digestion  and  to  avoid  emaciation. 

If  it  is  desired  to  test  motility  in  gastric  carcinoma  by  means  of 
our  method,— that  is,  by  the  "deglutable,  india-rubber  stomach- 
shaped  bag," — it  is  wise  not  to  distend  the  bag  too  much;  in  fact, 
in  cases  of  advanced  cancer,  the  use  of  any  intragastric  instrument 
except  the  stomach-tube  for  this  purpose  is  unjustifiable,  because, 
in  our  experience,  the  stomach-tube,  with  the  help  of  previous  test- 
meals,  has  been  found  perfectly  sufficient  to  ascertain  the  condition 
of  the  motility  in  this  disease.  The  peristalsis  may  be  studied  in 
hospitals  by  means  of  the  X-rays  and  capsules  of  bismuth  subnitrate 
swallowed  by  the  patient  (Boas  and  Levy  Dorn,  "Deutsch.  med. 
Wochenschr.,"  1898,  2).  The  course  of  the  capsule  can  be  readily 
observed  by  the  fluoroscope.  The  loss  of  secretion  in  gastric  cancer 
was  first  discovered  by  von  der  Velden  ("Deutsch.  Arch.  f.  klin. 
Med.,"  Bd.  xxiii,  S.  369,  1879).  The  diagnostic  value  of  the  absence 
of  free  HCl  in  the  gastric  contents  in  malignant  neoplasm  is  to-day 
universally  admitted.  There  are  other  diseases  (chronic  gastritis 
and  achylia  gastrica)  in  which  free  HCl  is  absent,  but  it  is  one  of  the 
most  constant  symptoms  of  gastric  cancer.     Only  in  the  carcinoma 


PERISTALSIS,  SECRETION,  AND  ABSORPTION  IN  CARCINOMA.       55  I 

that  arises  from  an  ulcer  do  we  find  HCl  present,  and  this  is,  in  our 
opinion,  explained  by  the  fact  that  ulcus  carcinomatosum  is,  in  the 
great  majority  of  cases,  reported  a  very  localized  affection  with  little 
or  no  disseminating  infiltration,  and  consequently  does  not  destroy 
the  glandular  apparatus  extensively.  We  should  not  conclude  our 
study  of  the  secretory  function  by  merely  testing  for  free  HCl.  In 
all  cases  an  artificial-digestion  experiment  should  be  made  with  egg- 
albumen  discs,  as  described  in  the  first  part  of  this  work,  and  the 
amount  of  the  HCl  deficit  determined. 

I  do  not  advocate  this  step  as  an  accurate  method  of  determining 
the  amount  of  combined  HCl  present ;  if  information  on  this  point  is 
required,  I  recommend  the  methods  of  von  Noorden  and  Honigman, 
or  the  method  of  Martins  and  Liittke.  Fortunately,  the  necessity 
for  these  analyses  is  A^ery  rare  in  practice.  What  is  essential  to  know 
is  how  far  behind  the  normal  the  HCl  secretion  is  in  suspected  cancer 
cases,  and  for  this  purpose  the  determination  of  the  HCl  deficit  is 
sufiicient.  The  absence  of  free  HCl  in  a  large  majority  of  cancer 
cases,  when  taken  in  conjunction  with  other  signs  and  symptoms, 
has  a  high  diagnostic  significance.  Although  absence  of  free  HCl 
occurs  in  chronic  or  atrophic  gastritis  and  achylia  gastrica,  in  pro- 
gressed cardiac  and  pulmonary  diseases  and  nervous  anacidity  these 
conditions  are  not  easily  mistaken  for  carcinoma.  Riegel  formerly 
suggested  that  the  HCl  was  destroyed  by  the  carcinomatous  tissue 
itself,  or  a  product  of  it ;  later  he  inclined  to  the  opinion,  now  gener- 
ally accepted,  that  the  loss  of  secretion  is  due  to  the  accompanying 
gastritis  or  actual  carcinomatous  invasion  of  the  secretory  glands. 
As  the  stomach  does  not  secrete  HCl  uniformly,— i.  e.,  over  all  its 
surface, — it  is  conceivable  that  a  carcinoma  may  occur  in  a  portion 
where  no  HCl  is  secreted  normally,  and  in  such  a  case  HCl  might  con- 
tinue undisturbed  as  long  as  the  neoplasm  does  not  extend.  The 
accompanying  gastritis  may  in  other  cases  be  limited,  and  therefore 
the  glandular  apparatus  remain  largely  intact.  We  have  observ^ed 
six  cases  in  which  the  presence  of  free  HCl  continued  to  the  end  of 
life.  In  two  the  neoplasm  was  seen  during  operation,  and  in  the 
remaining  four  at  autopsy.  These  six  cases  had  not  originated  on 
the  basis  of  an  old  gastric  ulcer,  but  were  rather  circumscribed  cancer 
masses  in  the  pyloric  antrum.  Absence  of  accompanying  gastritis, 
limited  carcinomatous  invasion  of  the  acid-producing  glandular 
portion,  or  location  in  the  portion  which  normally  secretes  HCl,  may 
serve  to  explain  the  cases  of  gastric  cancers  in  which  free  HCl  is  still 


552  MALIGNANT   TUMORS    OF    THE    STOMACH. 

detected.  They  are  so  rare,  however,  that  they  can  hardly  invalidate 
the  importance  of  the  sign.  Rosenheim,  Ewald,  Hammerschlag,  and 
the  author  have  examined  the  mucosa  from  stomachs  presenting 
carcinoma  originating  from  ulcers;  previous  test-meal  analysis  had 
revealed  an  amount  of  free  HCl  equal,  on  the  average,  to  0.12  per 
cent.     No  structural  changes  in  the  secretory  glands  were  observed. 

The  Jaworski  method  should  not  be  neglected  in  testing  for  the 
prozymogens  of  the  gastric  ferments.  About  200  c.c.  of  a  5 :  1000 
solution  of  HCl  are  poured  into  the  stomach,  after  it  has  been  pre- 
viously cleansed,  and  a  quantity  redrawn  in  twenty  minutes ;  if  this 
does  not  digest  egg-albumen  after  a  further  addition  of  HCl,  and  no 
rennin-zymogen  is  contained  in  it,  then  the  glandular  activity  is 
completely  extinguished.  The  state  of  the  resorption  is  very  much 
reduced,  according  to  Eichhorst,  Zweifel,  Wolff,  and  others.  Cap- 
sules of  three  to  five  grains  of  iodid  of  potash,  which  should  give  the 
iodin  reaction  in  the  saliva  fifteen  minutes  after  they  are  swallowed, 
do  not,  as  a  rule,  give  this  reaction  before  one  hour  to  one  and  a  half 
hours  have  expired. 

With  the  progressive  cachexia,  the  color  of  the  face  and  of  the  ex- 
ternal mucous  membrane  becomes  pale  or  yellowish.  There  is  per- 
sistent insomnia,  and,  as  a  consequence  of  the  hydremia  and  the 
impoverished  condition,  the  vessel  walls  become  more  permeable, 
producing  the  frequent  edema  at  the  ankles  and  other  dependent 
parts,  which  sometimes  invokes  suspicion  of  nephritis.  The  body 
weight  may  be  reduced  thirty  to  forty  pounds  in  from  one  to  two 
months.  The  urine  is  greatly  diminished  in  quantity,  concentrated, 
and  highly  colored,  as  a  result  of  the  impaired  absorption,  frequent 
emesis,  and  edema.  The  reaction  is  neutral  or  even  alkaline,  par- 
ticularly if,  by  methodical  lavage,  the  acids  and  acid  salts  have  been 
largely  removed.     An  excess  of  indican  is  found  in  the  urine. 

Von  Jaksch  demonstrated  the  presence  of  acetone  in  the  urine,  and 
Maixner  discovered  peptone  in  the  urine  of  twelve  cases  he  examined, 
and  his  results  were  confirmed  by  Parganowski.  IMaixner  attributes 
the  peptonuria  to  impairment  of  the  ability  of  the  gastric  membrane 
to  change  peptone  back  into  albumin,  while  Parganowski  believes 
that  the  formation  of  the  peptone  takes  place  in  the  disintegrating 
cancerous  tissue.  The  urine  also  gives  a  Burgundy-red  color  with 
chlorid  of  iron,  which  is  probably  due  to  diacetic  acid.  The  feces 
frequently  contain  undigested  muscle-fibers  and  egg-albumen  taken 
in  the  food.     There  is  pronounced  constipation  in  seventy-five  per 


SPECIAIy    SYMPTOMS — HEMATEMESIS.  553 

cent,  of  cases,  caused  principally  by  stenosis  of  the  pylorus,  and  in 
other  cases  by  the  greater  amount  of  work  that  the  intestine  is  called 
upon  to  perform  and  the  impaired  peristalsis.  In  twenty  per  cent, 
of  cases  there  is  diarrhea,  and  regular  evacuation  in  only  five  per 
cent. 

Special  Symptoms. — Hematemesis. — The  hemorrhages  from  gas- 
tric carcinoma  are,  as  a  rule,  not  abundant,  although  they  are  quite 
frequent.  They  are  most  frequently  observed  in  carcinoma  of  the 
pylorus  and  of  the  lesser  curvature.  As  hemorrhages  which  are  not 
copious  do  not  easily  lead  to  emesis,  there  is  sufficient  time  for  chang- 
ing of  the  blood  pigments  into  hematin,  which  is  uniformly  mixed 
with  the  gastric  contents,  so  that  when  they  are  eventually  vomited, 
they  present  the  appearance  of  coffee-grounds  or  dark  chocolate, 
which  is,  according  to  Brinton,  a  vomit  that  is  observed  in  about 
forty-two  per  cent,  of  the  cases,  and  is,  therefore,  an  important  sign 
in  gastric  cancer.  This  kind  of  vomit  may  also  occur  in  chronic  pas 
sive  congestion  of  the  stomach  and  in  ulcer.  In  chronic  gastritis  one 
rarely  meets  with  even  small  hemorrhage ;  there  is  no  diffuse  staining 
of  the  ingesta,  which  simply  shows  streaks  or  points  of  blood.  If  the 
coffee-ground  admixture  in  vomit  occurs  frequently  or  daily  for 
weeks,  then  it  becomes  an  important  pathognomonic  symptom  of  gas- 
tric malignant  neoplasm. 

The  Occurrence  and  Determination  of  Tumor. — In  all  cases  of 
suspected  carcinoma  of  the  stomach  the  examining  physician  should 
carefully  and  systematically  go  through  the  routine  of  inspection, 
palpation,  percussion  of  the  entire  abdomen,  and  artificial  distention 
of  the  stomach  by  air  or  gas.  When  an  abdominal  tumor  is  formed 
by  the  dilated  stomach  itself,  the  diagnosis,  in  the  majority  of  cases, 
can  be  made  by  a  simple  inspection.  To  determine  the  presence  of 
peristalsis  in  dilated  stomachs,  rarely  anything  else  than  close  in- 
spection is  necessar3^ 

There  are  two  conditions  in  which  the  stomach  itself  may  form  a 
palpable  tumor  by  chronic  contraction;  one  is  where  the  organ 
shrinks  in  consequence  of  occlusion  of  the  esophagus,  and  can  be  felt 
as  a  narrow,  firm  ridge  lying  below  the  left  lobe  of  the  liver;  the  other 
condition  is  known  as  cirrhosis  ventriciili,  and  is  the  result  of  chronic 
hyperplasia  of  the  walls,  with  subsequent  contraction  of  the  lumen. 
In  very  rare  instances  it  may  be  caused  by  diffuse  carcinomatous 
infiltration.  The  infiltrating  scirrhous  carcinoma  of  the  stomach, 
even  at  the  autopsy,  may  not  be  distinguishable  microscopically  from 


554  MAUGNANT   TUMORS    OF    THE    STOMACH. 

cirrhosis  of  the  organ,  the  author  having  observed  two  such  cases  in 
which  the  nature  of  the  gastric  induration  was  not  discoverable  from 
microscopical  study  of  the  sections  from  the  stomach  but  only  from 
the  metastases.  In  this  instance  we  are  concerned  most  directly 
with  the  nodular  and  massive  tumors  of  the  stomach. 

As  three-fifths  of  all  tumors  occupy  the  pyloric  region,  they  should 
not  escape  diagnostic  palpation,  because  in  the  majority  of  cases  they 
displace  the  pylorus  downward  and  render  it  palpable.  When  the 
stomach  is  filled  with  stagnating  food  or  water,  distended  by  gas,  or 
in  a  state  of  atony,  the  pylorus  is  generally  below  the  edge  of  the  liver. 
In  some  cases  where  the  abdominal  walls  are  not  too  thick,  it  is  possi- 
ble to  feel  and  recognize  the  normal  pylorus  as  a  small,  transversely 
placed  ridge,  which  varies  its  position  with  respiration.  Personally, 
I  have  occasionally  been  able  to  grasp  the  normal  pylorus  between 
the  fingers  of  the  left  hand,  and,  by  massage  and  compression  of  the 
fundus  by  the  right  hand,  been  able  to  recognize  the  escape  of  air  and 
liquid  ingesta  through  the  pyloric  ring.  The  detection  of  the  location 
of  the  pylorus  is  easier  in  dyspeptic  patients  than  in  the  normal  state, 
because  in  cases  in  which  it  becomes  important  to  recognize  the  py- 
lorus there  is  generally  considerable  emaciation  of  the  abdominal 
walls,  thus  facilitating  palpation.  Alternating  relaxation  and  con- 
traction of  the  pylorus  may  sometimes  be  felt,  but  this  phenomenon  is 
very  rare.  Osier,  in  his  ' '  Practical  Monograph  on  the  Diagnosis  of 
Abdominal  Tumors  "  (D.  Appleton  &  Co.,  1894),  sums  up  the  leading 
points  concerning  the  solid  tumors  of  the  stomach  in  the  following 
terms :  ' '  Though  only  a  small  section  of  the  stomach  is  available  for 
palpation,  a  very  large  proportion  of  all  tumors  of  the  organ  ma}^  be 
felt,  owing  in  part  to  their  greater  frequency  at  the  pyloric  portion, 
and  in  part  owing  to  the  frequent  depression  of  the  organ."  He  gives 
an  account  of  twenty-four  cases,  in  all  of  which  a  tumor  or  induration 
was  detected.  In  the  majority  of  the  cases  no  trouble  was  experi- 
enced in  determining  whether  or  not  a  tumor  was  in  the  stomach. 
Excessive  mobility  of  a  pyloric  growth  and  extensive  infiltrating 
masses  in  the  epigastric  region  were  the  only  conditions  causing 
trouble  in  any  of  the  cases  of  his  series.  As  other  forms  of  tumor  of 
the  stomach  (those  that  I  have  referred  to  in  the  sections  on  Malig- 
nant and  Benign  Tumors)  are  rare,  a  palpable  tumor  in  the  stomach 
may,  as  a  rule,  be  considered  a  carcinoma.  One  can  not  exclude 
carcinoma  even  when  a  palpable  tumor  is  absent,  because  twenty  per 
cent,  of  all  cases  escape  objective  demonstration  during  their  entire 


DIAGNOSIS    OF    GASTRIC    TUMORS.  555 

clinical  history  (Fleischer).  Among  these  cases  we  must  reckon  the 
cancers  affecting  the  cardia,  the  lesser  curvature,  and  part  of  those 
affecting  the  posterior  wall.  In  order  to  instruct  ourselves  concern- 
ing the  typical  peculiarities  of  a  tumor,  and  to  avoid  confounding  it 
with  neoplasms  of  adjacent  organs,  repeated  and  thorough  examina- 
tions are  necessary.  The  patient  should  be  placed  in  a  horizontal 
position,  his  knees  should  be  flexed,  and  his  mouth  kept  open,  and 
palpation  should  be  careful  and  gentle,  because  energetic  and  rapid 
palpation  does  more  harm  than  good,  as  it  produces  an  annoying  ten- 
sion of  the  abdominal  muscles.  We  are  in  the  habit  of  evacuating 
stomach  by  lavage,  and  also  the  entire  intestinal  tract  by  a  purge,  the 
prior  to  palpation,  in  order  to  bring  about  the  most  favorable  condi- 
tions for  this  examination. 

Occasionally,  a  tumor  will  be  evident  upon  simple  inspection  as  a 
round  or  oval  prominence,  but  the  results  of  palpation  are  more  relia- 
ble. The  cancer  can  be  felt  as  a  hard,  uneven,  sharply  circumscribed, 
nodular  tumor.  When  the  growth  has  extended  more  toward  the 
interior  of  the  stomach  and  brought  about  diffuse  infiltrations,  one 
feels  a  more  uniform,  and  frequently  only  an  indistinct,  resistance 
toward  the  depths  of  the  epigastrium  or  right  hypochondrium.  In 
the  beginning  of  a  carcinomatous  growth  at  the  pylorus  its  smooth 
contour  will  not  permit  of  a  positive  differentiation  from  benign 
hypertrophy,  especially  as  the  consecutive  symptoms  of  stenosis, 
gastritis,  and  dilatation  are  coincident  with  both.  In  this  case  the 
only  means  of  reaching  a  decision  is  by  watching  the  further  progress 
of  the  tumor.  When  the  stomach  is  filled  with  food  and  gases,  the 
tumor  is  less  distinct  on  palpation.  Persistent  and  stubborn  reflex 
cramp  of  the  pylorus  may  give  the  impression  of  carcinoma.  In  a 
case  reported  from  Leube's  clinic,  in  a  man  aged  thirty-six  years, 
who  had  a  dilatation  and  a  distinctly  palpable  tumor  in  the  umbilical 
region,  an  operation  was  decided  upon,  but  when  von  Heinecke  and 
Leube  reexamined  the  man  under  chloroform  anesthesia,  the  tumor 
had  disappeared ;  the  patient  was,  consequently,  not  operated  upon, 
and  was  reported  living  in  good  health  twelve  years  after  this  expe- 
rience. 

In  two  cases  at  my  clinic  gastric  tumors  were  mimicked  by  sub- 
epidermic  neoplasms  of  the  skin.  One  was  a  negress  with  an  elongate 
keloid  tumor  beneath  the  skin  of  the  epigastrium,  and  the  other  was  a 
white  male  who  had  been  presented  for  operation  for  gastric  cancer. 
On  examination  he  was  found  to  have  a  subcellular  lipoma  in  the 


'  556  MALIGNANT   TUMORS    OF   THE   STOMACH. 

abdominal  walls  over  the  epigastrium.     Distention  of  the  stomach 
will  prevent  errors  of  diagnosis  in  such  cases. 

Position  and  Movability  of  the  Tumor. — Three-fourths  to  five- 
sixths  of  the  normal  stomach  is  located  in  the  left  half  of  the  abdo- 
men; therefore  one  would  expect  that  gastric  tumors  are  generally 
palpable  in  the  epigastrium  a  little  to  the  left — rarely  to  the  right — of 
the  median  line,  and  above  the  umbilicus.  But  as  pyloric  neoplasms 
are  the  most  frequent  (sixty  per  cent.,  Welch),  these  will  be  found  to 
the  right  of  the  median  line.  Later  on,  the  tumor  sinks  downward 
more  and  more  and  can  be  demonstrated  below  the  umbilicus,  par- 
ticularly if  it  is  a  pyloric  neoplasm.  If  no  adhesions  exist,  it  may 
even  sink  down  into  the  pelvis.  When  there  are  adhesions  near  the 
locality  of  the  tumor,  it  is  immovable;  but  if  they  are  absent,  the 
tumor  may  be  moved  to-and-fro  to  some  extent.  Osier  {loc.  cit.) 
gives  some  clear  illustrations  of  the  positions  into  which  gastric 
tumors  can  be  moved.  Changing  the  position  of  the  body  brings 
about  a  moderate  movement  in  the  growth.  In  order  to  ascertain 
whether  a  tumor  belongs  to  the  stomach  proper,  the  changes  in  form 
and  position  of  the  organ,  which  are  caused  b}^  filling  the  same  with 
water  or  distending  it  with  air,  are  very  helpful.  If  on  filling  the 
stomach  with  water  the  tumor  lies  within  the  area  of  dullness  thus 
artificially  produced,  and  if  on  subsequent  distention  of  the  stomach 
with  CO3  a  tympanitic  resonance  can  be  made  out  above  and  below 
the  tumor,  it  belongs  to  the  stomach.  On  filling  the  colon  with  one 
to  two  liters  of  water  the  gastric  tumors  rise  upward,  and  may  hide 
behind  the  liver  and  sternum.  It  is  generally  stated  that  gastric 
tumors,  in  the  majority  of  cases,  do  not  move  with  respiration,  but 
that  tumors  of  the  liver  do.  There  are  many  exceptions  to  this  rule. 
If  there  are  any  adhesions  to  the  liver,  spleen,  or  diaphragm,  stomach 
neoplasms  participate  in  the  respiratory  movements  of  these  organs. 
If  the  tumor  is  of  considerable  size,  it  moves  downward  with  respira- 
tion, because  it  can  not  get  out  of  the  way  of  the  descending  dia- 
phragm. The  percussion-note  over  the  tumor  is  most  frequently  of 
a  dull,  tympanitic  character.  It  has  been  stated  that  only  hepatic 
tumors  give  a  dullness  on  percussion,  and  that  this  may  serve  to 
differentiate  them  from  the  stomach  tumors ;  this,  however,  is  a  mis- 
leading sign,  because  large  gastric  tumors  will  give  dullness  on  per- 
cussion, and  if  a  hepatic  tumor  is  located  at  the  margin  of  the  liver,  or 
if  a  few  loops  of  intestine  or  the  colon  lie  between  it  and  the  abdomi- 
nal wall,  a  tympanitic  percussion-note  will  result.     Pulsations  may  be 


DIFFERENTIATION    OF    ABDOMINAL   TUMORS.  557 

evident  in  tumors  that  are  adjacent  to  the  celiac  axis  or  superim- 
posed upon  the  aorta.  If  the  latter  is  compressed  by  the  tumor,  the 
tonicity  of  the  crural  pulse  is  diminished,  and  the  epigastric  growth 
may  mimic  an  aneurysm. 

Differentiation  of  Gastric  Tumors  from  Those  of  Adjoining 
Organs. —  i.  From  Splenic  Tttmors. — As  gastric  cancers  rarely 
occur  at  the  fundus,  their  differentiation  from  splenic  tumors  is  rarely 
called  for  and  is  seldom  difficult.  The  spleen  is  movable  with  respira- 
tion; the  stomach,  only  exceptionally.  In  splenic  tumor  we  have 
dullness  on  percussion  and  absence  of  dyspeptic  symptoms.  In  gas- 
tric tumor  we  have  a  tympanitic  resonance  on  percussion  and  dis- 
turbances of  secretion  and  motility.  Splenic  tumors  can  be  very 
often  mapped  out  and  found  to  be  ascending  back  of  the  ribs. 

2.  From  Tumor  of  the  Liver. — Hepatic  tumors  move  with  respira- 
tion, and  frequently  it  is  possible  to  grasp  the  gastric  tumor  and  sepa- 
rate it  from  the  liver.  The  contours  of  the  liver  should  be  deter- 
mined, if  possible;  for  with  hepatic  tumors,  the  liver  is  generally 
enlarged  and  sensitive  to  pressure,  and  the  surface  is  frequently  un- 
even. Phenomena  of  disturbance  of  hepatic  circulation,  such  as 
icterus  and  ascites,  denote  liver  tumor.  It  is  true  that  dyspeptic 
symptoms  may  be  secondarily  caused  by  malignant  disease  of  the 
liver,  but  then  they  present  themselves  later  in  the  disease;  wdth 
gastric  cancer  dyspeptic  symptoms  are  among  the  very  first.* 

3.  From  Malignant  and  Other  Tumors  of  the  Gall-bladder. — Carci- 
noma of  the  gall-bladder  and  accumulations  of  gall-stones  may  be 
confounded  with  pyloric  carcinoma.  The  latter  brings  on  gastric 
dilatation  and  grave  anomalies  of  function,  which  are  absent  in  affec- 
tions of  the  gall-bladder.  Cancers  of  the  gall-bladder  are  not  sec- 
ondary to  cancers  of  the  stomach,  as  a  rule.  If,  however,  the  gall- 
bladder tumor  presses  upon  the  pylorus,  and  also  causes  stenosis 
and  dilatation,  as  we  had  occasion  to  observe  at  an  autopsy  in  the 
Maryland  General  Hospital,  the  differentiation  from  gastric  neo- 
plasm is  practically  impossible.  The  assertion  that  hydrochloric  acid 
is  still  secreted  when  the  carcinoma  is  in  the  gall-bladder  and  not 
in  the  stomach,  is  not  supported  by  sufficient  evidence,  because 
passive  congestion  of  the  stomach  concomitant  with  gall-bladder 
and  hepatic  tumors  often  brings  about  loss  of  gastric  secretion. 

4.  Carcinoma  of  the  pancreas  has  frequently  deceived  clinicians  in 

*The  liver  itself  may  give  the  signs  and  symptoms  of  a  tumor  (see  chapter  on  Enter- 

optosis). 


558  MAL,IGNANT   TUMORS    OF   THE)    STOMACH. 

the  diagnosis  of  abdominal  tumors.  Its  immovability  during  res- 
piration and  palpation  might  suggest  pyloric  carcinoma;  pancreatic 
tumors,  however,  frequently  cause  stasis  in  the  portal  vein  and  pro- 
nounced icterus ;  while  dyspeptic  disturbances  and  loss  of  HCl,  which 
are  early  and  prominent  symptoms  of  gastric  cancer,  are  absent. 

5.  Tumors  of  the  Otnentum  and  Peritoneum. — The  differentiation 
of  these  tumors  from  gastric  carcinoma  is  difficult  when  symptoms  of 
disturbed  gastric  digestion  are  present  and  the  tumor  does  not  exceed 
the  limits  of  the  stomach.  As  a  rule,  these  tumors,  being  secondary, 
are  not  so  sharply  circumscribed  as  are  gastric  tumors.  Ascites  is 
rarely  absent.  The  original  source — the  primary  tumor  in  some 
other  organ — should,  if  possible,  be  discovered.  Sometimes  disease 
of  the  stomach  may  be  excluded  by  chemical  and  microscopical 
methods,  and  then  the  diagnosis  becomes  possible. 

6.  Tumors  of  the  colon,  as  a  rule,  sink  downward,  because  the  colon 
is  very  movable,  unless  (very  rarely)  adhesions  form  with  the  abdomi- 
nal wall.  By  alternately  filling  the  stomach  with  water  and  air,  and 
subsequently  evacuating  it  again,  it  may  be  demonstrated  that  the 
tumor  is  independent  of  the  stomach.  When  the  colon  is  filled  with 
one  to  two  liters  of  water,  the  tumor  rises  but  very  slightly,  if  at  all ; 
while  tumors  of  the  stomach,  on  filling  the  colon,  generally  ascend, 
and  may  disappear  behind  the  liver  or  sternum.  Tumors  of  the  ante- 
rior wall  of  the  colon  become  more  distinct  when  it  is  filled  with  water, 
while  those  of  the  posterior  wall  become  less  distinct.  A  stenosis, 
as  a  rule,  appears  promptly,  and  the  colon  becomes  tremendously 
expanded  in  front  of  the  constriction.  Osier  (loc.  cit.)  has  reported 
a  carcinoma  of  the  cecum  and  colon,  with  enormous  secondary  en- 
largement of  the  liver,  and  extensive  secondary  nodules  were  scat- 
tered through  the  lungs.  His  case  is  very  instructive,  as  the  intes- 
tinal symptoms  were  absent,  thus  illustrating  the  difficulty  in  making 
a  correct  diagnosis. 

7.  Duodenal  carcinoma  can  scarcely  be  separated  from  pyloric 
carcinoma.  The  occurrence  of  a  tumor  in  the  vicinity  of  the  um- 
bilicus, the  cachexia,  the  consecutive  gastric  dilatation,  and  (if  the 
duodenal  carcinoma  should  ulcerate)  the  coffee-ground  vomit — all 
these  signs  may  be  present  in  cancers  of  either  locality.  If  free  HCl 
can  be  demonstrated  in  the  gastric  contents,  or  its  secretion  can  be 
caused  after  methodical  lavage,  the  other  symptoms  of  neoplasm 
might  possibly  be  referred  to  the  duodenum.  Carcinoma  of  the  duo- 
denum, as  Hwald  and  Riegel  have  observed,  may  be  combined  with 


COMA   CARCINOMATOSUM.  559 

atrophic  gastritis,  so  that  absence  of  HCl  may,  in  these  cases,  occur, 
which  absence  is  not  directly  caused  by  a  gastric  carcinoma ;  hence, 
the  diagnosis  is  largely  a  matter  of  chance.  The  author's  method  of 
duodenal  intubation  may  be  available  in  determining  a  duodenal 
stenosis.  It  is  evident  that  a  thorough  knowledge  of  gastric  cancer 
and  the  application  of  all  physical  and  chemical  methods  of  diagnosis 
is  necessary  if  we  wish  to  be  approximately  correct  in  our  diagnosis. 
In  all  cases  of  doubtful  differential  diagnosis  exploratory  laparotomy 
should  not  be  deferred  until  the  loss  of  strength  of  the  patient  con- 
traindicates  operation. 

Cachexia. — As  the  gastric  cancer  progresses,  anemia  and  emacia- 
tion increase  to  a  pronounced  cachexia.  The  color  of  the  skin  be- 
comes grayish-white  or  yellow;  it  may  appear  wrinkled,  atrophic, 
and  exfoliating.  Frequently  an  annoying  pruritus  is  present.  The 
body  weight  becomes  less  and  less  the  more  digestion  is  disturbed; 
the  severer  the  vomiting,  the  more  the  passage  of  chyme  into  the 
intestine  becomes  obstructed.  The  blood  grows  more  and  more 
deficient  in  red  blood-corpuscles  and  in  hemoglobin,  and  a  state 
similar  to  pernicious  anemia  may  result.  Pronounced  diminution 
of  the  hemoglobin  is  so  constant  an  accompaniment  of  gastric  cancer 
that  it  can  almost  be  excluded  in  case  the  amount  of  hemoglobin  is 
equal  to  sixty  per  cent,  or  more  (Haberlin-Eichhorst).  The  amount 
may  sink  to  forty  and  thirty  per  cent.  In  one  case  of  Eichhorst's  it 
sank  to  ten  per  cent.  Accidental  sounds  about  the  heart  and  signs 
of  cerebral  anemia  or  of  moderate  edema  have  been  observed.  As- 
cites is  a  consequence  of  secondary  metastases  in  the  liver  or  peri- 
toneum, or  of  thrombosis  in  the  portal  vein;  but  toward  the  end  of 
life  it  may  be  caused  by  great  cardiac  asthenia  and  hydremia.  Throm- 
bosis of  the  main  vessels  of  one  leg  has  been  observed,  and  constitutes 
a  very  fatal  sign.  The  pulse  is  mostly  accelerated,  and  the  body 
temperature  is  subnormal.  Fever  is  a  rare  occurrence  in  gastric 
cancer ;  if  it  does  occur,  it  is  traceable  to  autointoxication  with  septic 
products  formed  in  the  ylceration  or  degeneration  of  the  cancer. 

Coma  carcinomatosum  is  a  complication  of  symptoms  similar  to 
the  coma  of  diabetics,  and  is  accompanied  by  a  peculiar  dyspnea. 
The  respirations  are  strong  and  deep,  and  generally  attended  with  a 
groaning  sound  in  expiration.  The  rate  of  respiration  is  either  nor- 
mal or  moderately  increased.  The  temperature  is  either  normal  or 
subnormal.  There  is  no  evidence  of  disease  of  the  lungs  or  air-pas- 
sages. It  does  not  usually  appear  until  anemia  is  far  advanced. 
37 


560  MALIGNANT   TUMORS    OF    THE   STOMACH. 

This  kind  of  coma  was  first  described  by  Fetters  and  Kaulich,  and 
later  by  von  Jaksch  ("Wien.  med.  Wochenschr.,"  1883,  p.  473),  and 
is  probably  a  consequence  of  autointoxication.  (See  literature  of 
this  subject  in  Albu,  "  Autointoxicationen  des  Intestinaltractus, " 
Berlin,  1895,  p.  105.) 

As  we  have  stated  in  the  pathology  of  carcinoma,  swellings  of  the 
peripheral  lymph-glands  are  not  rare  at  autopsies.  A  hard  swelling 
of  the  supraclavicular  glands  was  considered  typical  by  Friedreich 
and  Henoch.  I  find  that,  clinically,  swelling  of  the  cervical  lymph- 
glands  is  a  rare  sign,  and  occurs  only  toward  the  end  of  the  disease, 
by  which  time  the  diagnosis  is  generally  clear.  If  severe  vomiting 
ceases  suddenly,  a  breaking  down  of  the  cancerous  infiltration  of  the 
pyloric  region  may  be  inferred, — by  which  communication  with  the 
intestines  may  be  restored, — or  it  may  be  due  to  excessive  muscular 
insufficiency. 

Carcinomatous  Ulcer  (Ulcus  Carcinomatosum). — We  have 
already  stated,  in  the  section  on  the  Pathology  of  Gastric  Ulcer,  that 
atypical  cell-proliferation  may  develop  from  a  benign  gastric  ulcer, 
which  thereafter  entirely  assumes  the  character  of  a  carcinoma. 
Rokitansky  and  Dittrich  were  the  first  to  describe  this  condition,  but 
Hauser  ("Das  chronische  Magengeschwiir, "  Leipzig,  1883)  gave  the 
most  accurate  histological  description  of  it.  In  1891  Kollmann 
("Berlin,  klin.  Wochenschr.,"  1891,  5  und  6)  reported  fourteen  cases, 
to  which,  up  to  the  present  time,  as  far  as  we  know,  about  fourteen 
more  can  be  added  from  literature.  In  this  form  of  carcinoma  the 
gastritis  is,  at  the  beginning  at  least,  limited  to  the  immediate  neigh- 
borhood of  the  ulcer,  or  it  may  be  entirely  absent.  Accordingly,  the 
functional  disturbances  are  less,  and  secretion  may  be  normal,  or  we 
may  even  find  hyperchylia.  Very  late  in  the  course  of  this  type  the 
remainder  of  the  mucosa  may  suffer  from  cancerous  infiltration  or 
gastritis,  just  as  is  the  case  with  the  ordinary  gastric  carcinoma,  and 
then  the  functional  disturbances  become  more  pronounced.  The 
diagnosis  of  carcinomatous  ulcer  can  be  made  if  a  tumor  can  be  recog- 
nized, together  with  normal  or  excessive  secretion  of  HCl  and  a  pro- 
gressive cachexia.  Of  course,  the  previous  history,  which  gives  an 
account  of  years  of  gastric  pain, — whereas  cancer  patients  have,  as  a 
rule,  when  they  present  themselves  not  suffered  so  long, — is  a  valua- 
ble factor  in  the  diagnosis.  If  vomiting  of  blood  or  melena  occurs  in 
the  clinical  history,  the  diagnosis  becomes  probable,  but  it  is  difficult 
to  distinguish  between  carcinomatous  ulcer  and  the  tumor-like  indu- 


FRAGMENTS   SHOWING   MITOSIS.  561 

ration  of  a  large  simple  ulcer.  It  is  also  difficult  to  distinguish  the 
carcinomatous  ulcer  from  hypertrophic  stenosis  of  the  pylorus. 
Sometimes  the  recognition  of  secondary  metastases  in  the  liver,  or 
other  signs  of  cancerous  dissemination,  such  as  ascites  and  peritoneal 
carcinosis,  may  be  deciding  factors.  In  one  of  our  cases  there  was  no 
tumor  to  be  felt,  only  symptoms  of  cachexia  and  of  gastric  ulcer. 
For  literature,  see  Rosenheim,  ' '  Zur  Kenntniss  des  mit  Krebs  com- 
plicirten  runden  Magengeschwiirs,"  "Zeitschrift  f.  klin.  Medicin," 
Band  xvii,  Seite  116;  also  Boas  (loc.  cit.),  second  edition,  1895,  pages 
188  and  189,  and  Hemmeter,  "New  York  Med.  Record,"  volume  lii, 
No.  II,  September  11,  1897,  page  365.  D.  D.  Stewart  has  reported  a 
case  in  which  two  isolated  carcinomatous  ulcers  occurred  in  the 
stomach  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1898). 

Perforations. — When  a  carcinoma  perforates  into  other  hollow 
organs,  or  exteriorly,  life  may  be  maintained  for  a  short  time,  but  per- 
foration into  the  pleural  or  pericardial  cavities,  or  into  the  lungs, 
rapidly  leads  to  death.  Gastrocolic  fistulge  cause  very  rapid  emacia- 
tion, because  the  ingesta  pass  directly  into  the  colon,  in  which  very 
little  digestion  and  resorption  occur.  With  this  kind  of  perforation, 
portions  of  excrement  may  be  vomited.  Bronchitis,  traumatic 
pneumonia,  and  pericarditis  may  accompany  the  disease.  Tuber- 
culosis may  be  combined  with  gastric  carcinoma. 

Diagnosis. — The  majority  of  authors  say  that  fragments  of  the 
cancer  rarely  occur  in  the  vomit  or  are  rarely  brought  up  in  the  tube. 
In  fact,  it  appears  that  the  finding  of  carcinomatous  particles  is  con- 
sidered an  accident.  It  is  probable  that  this  occurrence  is  said  to  be 
so  rare,  not  because  these  fragments  do  not  occur  in  the  vomit  or 
wash-water,  but  because  they  are  not  methodically  and  systemati- 
cally looked  for.  The  great  importance  of  an  early  diagnosis  of  car- 
cinoma justifies  the  clinician  in  going  to  some  trouble  in  order  to  find 
these  fragments.  We  are  in  the  habit  of  feeding  all  suspected  cases 
for  forty-eight  hours  by  the  rectum.  Thereafter,  the  stomach  is 
washed  out  with  normal  salt  solution;  for  this  purpose  we  use  a 
stomach-tube,  which,  though  quite  soft,  is  provided  with  an  edge  of 
the  usual  firmness  around  the  lower  opening.  This  tube,  on  being 
moved  about  in  the  stomach,  is  very  likely  to  dislodge  surface  parti- 
cles of  the  neoplasm.  There  is  every  reason  why  we  should  inten- 
tionally attempt  to  secure  cancer  particles  from  the  stomach  just  as 
they  are  secured  by  cureting  from  the  uterus.  We  have  been  able,  in 
this  manner,  to  find  particles  of  the  neoplasm  in  the  wash-water  after 


562  MALIGNANT   TUMORS    OF   THE    STOMACH. 

it  has  been  permitted  to  settle  in  a  conical  glass  for  about  six  hours,  or 
after  the  solid  particles  were  brought  down  with  the  centrifuge. 
When  the  sediment  in  the  bottom  of  the  glass  is  first  examined  by  a 
low  power,  and  afterward  by  the  higher  power  of  the  microscope, 
cells  in  a  state  of  atypical  mitosis  can  frequently  be  found.  Previous 
to  the  rectal  feeding,  we  wash  out  the  stomach  thoroughly  in  order 
to  avoid  confounding  cancer  particles  with  particles  of  meat,  etc., 
retained  with  the  ingesta.  If  this  method  is  systematically  followed, 
we  believe  that  cancer  particles  will  be  more  frequently  found;  nor 
should  we  always  deny  the  existence  of  carcinoma  when  we  find  no 
fragment  giving  the  typical  histological  structure  of  these  neoplasms, 
as  described  under  their  pathology. 

Whenever  we  find  pieces  of  mucosa  in  which  the  glandular  ducts 
are  elongated  and  dilated,  and  the  cells  present  numerous  karyokine- 
tic  figures,  and  when  asymmetrical  and  hypochromatic  forms  are 
found,  the  possibility  of  the  existence  of  carcinoma  should  suggest 
itself,  even  when  typical  carcinoma  cells  are  absent;  particularly 
when  the  interstitial  tissue  is  considerably  increased  and  broadened, 
showing  much  small,  round-cell  infiltration  when  numerous  eosino- 
philic cells  are  present  and  the  parietal  or  oxyntic  cells  have  disap- 
peared, and  are  replaced  by  cylindrical  or  cuboidal  epithelial  cells, 
which  proliferate  down  into  the  peptic  ducts  from  the  vestibular 
alveoli. 

Whenever  cancer  is  suspected,  the  wash-water  should  be  obtained 
from  the  fasting  stomach  in  the  morning,  before  any  food  is  taken ; 
preferably,  the  contents  should  be  drawn  by  the  expression  method 
without  dilution,  and  any  cellular  detritus  brought  down  by  the  cen- 
trifuge. In  speaking  of  Rieder's  pioneer  work  in  this  direction, 
George  Dock  ("Cancer  of  the  Stomach  in  Early  Life,"  "Am.  Jour, 
of  the  Med.  Sciences,"  June,  1897,  p.  655)  expresses  himself  as  follows : 
"It  was  therefore  a  matter  of  great  interest  when  Rieder  ('Deutsches 
Archiv  fiir  klin.  Med.,'  Bd.  Liv,  H.  6,  S.  544)  reported  a  case  in  which 
he  made  a  diagnosis  of  malignant  disease  of  the  peritoneum  and 
pleura  from  finding  numerous  cells  in  the  exudates,  showing  indirect 
nuclear  division."  The  patient  was  a  woman  of  forty  years.  "Sec- 
tion showed  sarcoma  (carcinoma?)  of  the  peritoneum,  probably  sec- 
ondary to  malignant  disease  of  the  ovaries."  In  the  fluids  obtained 
during  life,  cells  were  found  which  were  remarkable,  "in  the  first 
place,  on  account  of  the  differences  in  size  and  shape  of  the  individual 
cells.     Often  there  were  indentations  and  constrictions,  sometimes 


THE    EARLY   DIAGNOSIS    OF    GASTRIC    CANCER.  563 

buddings.  In  many  cells  there  were  one  or  many  vacuoles,  often  so 
large  that  the  nucleus  was  pushed  to  one  side,  sometimes  hardly 
visible.  The  nuclei  varied  in  size  and  number."  The  examination 
of  the  stained  cells  showed  large  numbers  of  cells  in  a  state  of  indirect 
division,  and  especially  cells  with  atypical  mitoses. 

' '  The  most  remarkable  features  of  the  sediment  are  presented  by 
the  great  number  of  karyokinetic  figures.  These  are  especially  com- 
mon in  cells  from  twelve  to  eighteen  micromillimeters  in  diameter. 
The  protoplasm  of  these  cells  is  usually  more  homogeneous  than  that 
of  others.  Vacuoles  sometimes  occur,  and  in  rare  cases  the  proto- 
plasm may  be  very  much  degenerated.  Mitoses  are  so  numerous  that 
every  field  contains  one  or  more.  Often  two  to  five  can  be  seen  in  a 
small  field.  Various  stages  of  nuclear  and  cell-division  are  present. 
The  most  common  is  that  of  the  equatorial  plate.  The  spirem  and 
the  monaster  are  uncommon.  The  metaphase  is  not  so  easily  recog- 
nizable, partly  on  account  of  the  obscurity  of  many  of  the  figures. 
The  anaphase  is  common." 

Cells  containing  more  than  one  nucleus,  and  with  the  nuclei  in 
different  stages,  are  also  common.  In  these  cells  one  or  more  of  the 
nuclei  are  in  the  resting  stage,  and  one,  or  sometimes  more,  in  various 
stages  of  indirect  division  and  sometimes  showing  an  atypical  figure. 

The  mitoses  found,  so  far  as  they  can  be  studied  by  the  chromatin 
alone,  show  all  the  common  abnormalities.  Thus,  we  find  hypo-  and 
hyperchromatic  nuclei,  the  latter  being  rare.  Giant  mitosis  may  be 
represerited  by  the  tripolar  figure.  Asymmetrical  mitosis  is  not  easy 
to  recognize,  on  account  of  the  imperfect  preservation  of  the  chro- 
mosomes in  many  cases.  The  examples  of  mitosis  in  multinuclear 
cells  resemble  often  the  figures  given  by  Krompecher  ("Ueber  die 
Mitose  mehrkerniger  Zellen,  und  die  Beziehung  zwischen  Mitose  und 
Amitose,"  "Archiv  f.  path.  Anat.,"  Bd.  cxlii,  S.  447). 

The  interesting  history  of  atypical  mitosis  can  only  be  touched  on 
here.  Hberth  ("Archiv  f.  path.  Anat.  und  Physiol.,"  Bd.  Lxvii)  was 
the  first  to  describe  division  into  four  parts,  but  his  statements  were 
at  first  discredited  by  Flemming  and  Strassburger.  Later,  however, 
Arnold  {ibid.,  Bd.  Lxxxiii)  found  multiple  karyokinesis  in  carcinoma. 
He  thought  the  process  might  result  in  polynuclear  cells.  Since  then 
a  great  deal  of  work  has  been  done  on  this  subject,  much  of  it  being 
excited  by  the  ingenious  speculations  of  Hansemann.  From  an  ex- 
amination of  the  work  done  so  far  it  appears  that  atypical  mitoses  are 
found  in  various  pathological  conditions,  not  only  in  new  growths, 


564  MAIvIGNANT  TUMORS   OF  TH^   STOMACH. 

like  cancer  and  sarcoma,  but  also  in  benign  tumors  and  in  regenera-. 
lions;  in  short,  "in  all  tissues  of  strong  reproductive  activity  and 
when  there  is  active  mitosis"  (Strobe).  They  are  also  found  in  tis- 
sues irritated  by  various  poisons,  such  as  quinin,  chloral,  nicotin,  etc., 
or  in  tissues  exposed  to  high  temperature  (Galeotti).  In  cancer  all 
observers  find  them  in  great  richness  and  variety,  but  the  view  that 
the  presence  of  even  a  large  number  of  pathological  mitoses  in  a  tissue 
justified  the  diagnosis  of  cancer  is  gradually  being  abandoned.  As 
the  literature  is  quoted  in  the  works  of  Hansemann  ("Archiv  f.  path. 
Anat.,"  Bd.  cxix,  S.  299,  Bd.  cxxiii,  S.  356,  Bd.  cxxix,  S.  436; 
"Studien  iiber  die  Specificitat  den  Altruismus  und  die  Anaplasis  der 
Zellen,"  Berlin,  1893),  Strobe  ("Beitrage  zur  path.  Anat.,"  Bd.  xi, 
xiv,  Cornil  ("Journal  de  I'Anat.  et  de  la  Physiol.  Norm,  et  Path.," 
1891,  tome  xxvii,  p.  97),  and  Galeotti  ("Beitrage  zur  path.  Anat.," 
Bd.  XIV,  xx),  it  is  not  necessary  to  give  a  complete  bibliography  here 
(George  Dock,  loc.  cit.). 

Dock's  studies  {loc.  cit.)  concern  only  the  exudates  and  transudates 
in  suspected  carcinoma  of  pleura  and  peritoneum.  The  author,  in 
applying  the  method  to  examination  of  particles  from  carcinomatous 
stomachs,  concludes  that  although  the  presence  of  a  large  number 
of  cells  in  stomach-contents  showing  atypical  mitosis  is  not  pathog- 
nomonic of  carcinoma,  nevertheless  it  is  very  significant,  and  should 
stimulate  further  clinical  investigation  toward  positive  demonstration 
of  existence  of  malignant  gastric  neoplasm. 

We  have  found  in  one  case,  four  weeks  before  the  tumor  at  the 
pylorus  was  palpable,  portions  of  gastric  mucosa,  in  which  the  glandu- 
lar ducts  were  very  closely  packed,  containing  numerous  leukocytes 
and  showing  a  marked  atypical  appearance  of  the  glandular  epithelia, 
differing  from  the  normal  gland-cells  by  intense  pigmentation  of  the 
nuclei  and  much  darker  staining  of  the  protoplasm,  together  with 
marked  increase  of  the  connective  tissue,  small,  round-cell  infiltration, 
and  in  portions  disappearance  of  the  peptic  cells,  cylindrical  epithe- 
lial cells  having  replaced  them.  In  a  second  case  an  abundance  of 
cells  showing  atypical  mitosis  were  found  after  cureting  the  stomach, 
and  the  diagnosis  of  cancer  made  three  months  before  a  tumor  became 
palpable,  which  at  operation  proved  to  be  a  carcinoma  of  the  posterior 
wall.  There  was  no  marked  Uffelmann  reaction  for  lactic  acid  in  this 
case,  but  HCl  free  and  combined  was  absent  at  every  test-meal.  Such 
appearances  in  fragments  should  stimulate  further  careful  and  fre- 
quent examinations.     Sooner  or  later,  in  our  experience,  a  frag- 


THE    EARLY    DIAGNOSIS    OF    GASTRIC    CANCER.  565 

merit  will  be  obtained  which  will  give  the  typical  structure  of  car- 
cinoma. 

Concerning  the  significance  of  the  Oppler-Boas  bacillus  we  have 
already  spoken  in  the  first  part  of  this  work.     We  can  confirm  the 
opinions  of  the  authors  quoted,  that  this  organism  is  a  very  important 
diagnostic  sign  in  this  disease.     My  associate,   Dr.  Harry  Adler,  and 
myself  have  thus  far  examined  fifty-five  cases  of  gastric  carcinoma, 
and  found  the  organism  present  in  fifty-two.     Lactic  acid  is  a  valua- 
ble sign  of  intragastric  fermentation,  due  to  stagnation  from  dilata- 
tion and  stenosis.     It  is  not  pathognomonic  of  gastric  cancer,  be- 
cause it  may  not  be  present  in  excess  even  in  cancer,  provided  the  gas- 
tric peristalsis  is  unimpaired ;  and,  again,  it  may  be  present  when  the 
p3doric  stenosis  is  due  to  a  benign  obstruction.     However,  as  the 
majority  of  gastric  cancers  destroy  the  motility  and  cause  obstruc- 
tion, lactic  acid,  notwithstanding  the  exceptions  reported  (William 
S.  Thayer),  is  a  valuable  diagnostic  sign.     See  "A  New  Test  for  Lactic 
Acid  in  Gastric  Contents,"  J.  P.  Arnold, "The  Journal  of  the  American 
Med.  Association,"  August  21,  1897.     This  is  a  modification  of  the 
chlorid  of  iron  test,  but  not  so  accurate  as  that  given  on  page  171. 
Tactic  acid  is  formed  in  the  stomach  by  the  action  of  lactic  acid  bacilli 
on  carbohydrates.     Sticker  has  proved  that  the  simple  passage  of 
carbohydrates  through  the  mouth  causes  the  formation  of  more  or  less 
lactic  acid  without  exception ;  the  amount  formed  in  this  way  is  too 
small  to  be  discovered  by  the  Uffelmann  test. 

Four  conditions  are  necessary  to  effect  excessive  formation  of  lactic 
acid  in  the  stomach;  these  are:  (i)  Impaired  gastric  peristalsis, 
which  means  stagnation;  (2)  absence  of,  or  great  reduction  of,  HCl 
secretion;  (3)  reduction  of  albumin  digestion,  and  (4)  impaired 
absorption.  Although  there  may  be  stagnation  and  reduction  or 
absence  of  HCl  secretion,  lactic  acid  will  not  form  in  the  stomach  if 
the  proteid  digestion  is  fairly  good  and  does  not  fall  below  seventy- 
five  per  cent.  Whenever  there  is  much  lactic  acid  in  the  stomach,  the 
proteid  digestion  will  usually  be  below  fifty  per  cent,  or  entirely  ab- 
sent. The  importance  of  impaired  albumin  digestion  as  a  factor  in 
the  formation  of  lactic  acid  has  been  first  emphasized  by  Hammer- 
schlag  and  confirmed  by  Lindner  and  Kuttner.  It  is  indispensable 
to  investigate  the  combining  power  that  proteids  have  for  free  lactic 
acid  in  this  connection,  for  this  organic  acid  can,  to  a  certain  extent, 
replace  HCl  in  proteolysis.  If,  as  Hammerschlag  points  out,  lactic 
acid  is  absent  when  albumin  digestion  is  perfect,  or  rather  above 


566  MALIGNANT  TUMORS   OF  THE   STOMACH. 

seventy-five  per  cent.,  although  the  other  conditions  may  exist,  the 
question  arises.  How  much  of  the  already  formed  lactic  acid  may  have 
entered  into  combination  with  the  albumin  of  the  food  (in  the  ab- 
sence of  HCl)  and  thus  escaped  detection? 

(i)  In  the  progress  of  gastric  carcinoma  the  secretion  of  HCl 
suffers  first  (destruction  of  oxyntic  cells) ;  then  (2)  the  formation  of 
pepsin  and  rennin  becomes  impaired — the  loss  of  pepsin  brings  on 
the  defective  albumin  digestion ;  (3)  lactic  acid  fermentation  follows 
as  a  third  step,  requiring,  in  addition  to  the  other  two  conditions,  the 
factor  of  stagnation. 

The  accuracy  of  the  diagnosis,  upon  which  the  success  of  any  possi- 
ble operation  must  depend,  is  based  on:  (i)  The  recognition  of 
tumors;  (2)  the  finding  of  cancerous  particles  in  the  wash-water; 
(3)  demonstration  of  the  Oppler-Boas  bacillus;  (4)  the  excess  of 
lactic  acid;  (5)  the  absence  of  HCl  and  ferments,  reduced  or  absent 
albumin  digestion — by  the  filtrate  of  the  gastric  contents;  (6)  the 
occurrence  of  hematemesis  and  melena;  (7)  the  loss  of  motility  and 
presence  of  gastrectasia ;  (8)  the  general  symptomatology  and  anam- 
nesis. 

The  early  diagnosis  is  possible  only,  as  far  as  I  can  judge  at  present, 
by  frequent  microscopical  examinations  of  curetings  from  the  gastric 
mucosa  which  are  very  significant  if  they  give  evidence  of  numerous 
atypical  mitoses.  In  any  case,  showing  absence  of  HCl  together  with 
any  one  single  sign  of  the  others  just  enumerated,  that  does  not  im- 
prove under  three  weeks  of  treatment,  exploratory  laparotomy  should 
be  advised.  (Hemmeter,  "The  Early  Diagnosis  of  Cancer  of  the 
Stomach,"  "New  York  Medical  Record,"  October  21,  1899,  p.  577.) 

Carcinoma  of  the  Cardia. — Signs  and  Symptoms. — Complaints  of 
an  uncomfortable  feeling,  as  of  a  foreign  body,  and  of  pressure  above 
the  gastric  region,  particularly  after  the  ingestion  of  food.  Sensations 
of  pain  are  not  contemporaneous  with  swallowing  of  food,  but  occur 
independently.  On  ingestion  of  food  a  sensation  as  if  the  same  be- 
comes clogged,  or  is  caught  before  it  reaches  the  stomach ;  patients 
imagine  that  copious  drafts  of  water  give  relief,  most  likely  because 
this  can  pass  through  the  stenosis  caused  by  the  neoplasm.  Another 
important  symptom  is  vomiting,  which  is  not  actual  gastric  vomit, 
but  the  retching  up  of  mucus  and  a  few  food  particles  containing  no 
HCl.  The  cause  of  these  regurgitations  of  masses  of  mucus  is  the 
formation  of  a  large  dilatation  of  the  esophagus  above  the  stenotic 
carcinoma  of  the  cardia.     In  this  esophageal  diverticulum  or  dilata- 


DIAGNOSIS    OF    CARCINOMA    OP   THE    CARDIA.  567 

tion  the  food  is  caught,  retained,  putrefies,  and  is  eventually  vomited 
up  again.  There  is  also  a  septic  catarrhal  esophagitis  present  at  this 
place.  Liquid  or  semiliquid  substances  may  for  a  long  time  be  able 
to  pass,  while  relatively  solid  substances  give  rise  to  the  difficulties 
stated.  Later  on,  as  the  stenosis  increases,  liquids  can  not  pass  either, 
and  loss  of  appetite  and  strength  goes  on  uninterruptedly. 

If  an  obstacle  to  the  passage  of  the  sound  can  be  ascertained  at  the 
entrance  to  the  stomach  in  a  person  over  thirty  years  of  age,  the  diag- 
nosis of  cancer  of  the  cardia  becomes  certain.  In  all  such  suspected 
cases  only  a  soft  elastic  tube  should  be  used  for  explorative  sounding. 
In  a  number  of  cases  in  private  practice  I  was  enabled  to  establish 
the  diagnosis  by  microscopical  examination  of  small  portions  of  the 
carcinoma  that  were  brought  up  with  the  sound.  These  neoplastic 
fragments  are  occasionally  found  in  the  eye  of  a  lower  opening  of  the 
sound,  and  they  constitute  a  definite  criterion.  In  one  of  the  fore- 
going cases  the  diagnosis  was  confirmed  by  Dr.  M.  Einhorn,  and  in  the 
other  by  autopsy.  In  addition  to  the  sounding  and  the  cancerous 
fragments,  the  following  signs  are  of  diagnostic  importance : 

1.  Percussion  of  the  region  over  xiphoid  cartilage  is  very  painful. 

2.  On  the  sound  blood  will  frequently  be  found  rftixed  with  the  ex- 
tremely fetid  mucus,  and  at  times  nests  of  cancer  cells. 

3.  On  placing  a  stethoscope  over  the  epigastrium,  normally  two 
deglutition  sounds  can  be  heard.  One  is  synchronous  with  the  be- 
ginning of  the  act  of  swallowing,  and  the  other  is  heard  from  seven  to 
twelve  seconds  later.  In  carcinoma  of  the  cardia  the  second  degluti- 
tion sound,  which  signifies  the  entrance  of  liquid  into  the  stomach, 
may  be  much  delayed  or  absent  entirely;  this  sign  is  of  importance 
per  se. 

4.  Supraclavicular  swelling  of  the  lymph-glands,  if  palpable,  sup- 
ports the  diagnosis,  but  this  is  a  rare  sign  in  my  experience. 

5.  Lauenstein  asserts  that  there  is  a  systolic  murmur  audible  in  the 
epigastrium,  due  to  pressure  of  the  tumor  upon  the  aorta.  Accord- 
ing to  Boas  this  is  an  inconstant  sign. 

Duration  of  the  disease  is  six  to  nine  months  after  the  first  symp- 
toms are  manifested ;  death  occurs  as  a  result  of  gradual  exhaustion, 
marasmus,  aspiration  pneumonia,  secondary  carcinomata  in  the 
liver  and  other  organs,  and  intercurrent  hemorrhages. 

Differential  diagnosis  from  chronic  gastritis  is  difficult  in  the  begin- 
ning of  cancer  of  the  cardia,  as  in  both  the  presence  or  absence  of 
hydrochloric  acid  is  no  criterion;  but  as  the  cancer  progresses,  the 


568  MAIvIGNANT   TUMORS    OF   THE   STOMACH. 

sound  will  settle  the  doubt  in  locating  the  stenosis.  From  esophageal 
ulcer  the  cardia  carcinoma  is  differentiated  by  the  fact  that  pain  is 
immediately  associated  with  deglutition  of  food,  by  the  age  of  patient 
(see  tables  of  ages  at  which  ulcer  and  cancer  are  most  frequent),  by 
the  hematemesis  and  the  blood}^  stools  of  ulcer.  Ulcer  of  the  esoph- 
agus is  extremely  rare  in  comparison  to  cancer. 

From  diverticulum  the  cardia  carcinoma  is  differentiated  by  the 
following  facts :  Diverticulum  is  frequent  in  the  upper  third,  rare  in 
the  lower  third,  of  the  esophagus.  The  permeability  of  the  gullet  will 
be  more  variable  than  in  cancer,  because  the  sound  will  often  skip  the 
diverticulum.  In  the  latter  there  will  rarely  be  pain,  and  the  maras- 
mus will  not  be  so  progressive  and  rapid.  From  cardiospasm,  or 
cramp  of  the  cardia,  the  carcinoma  is  differentiated  by  the  occasional 
free  passage  of  the  thickest  tubes  in  the  neurosis,  which  occurs  almost 
exclusively  in  neurasthenics.  Nutrition  is  not  so  much  damaged  as 
in  cancer. 

If  tuberculosis  or  syphilis  is  present,  one  must  think  of  the  possibil- 
ity of  the  neoplasm  being  caused  by  these  diseases. 

Syphilis  may  be  excluded  or  diagnosed  by  the  effect  or  non-effect  of 
specific  treatment,  and  tuberculosis  by  the  effect  of  hypodermic  injec- 
tion of  minute  doses  of  tuberculin. 

Treatment  of  Cardia  Carcinoma. — So  long  as  there  is  no  cure  possi- 
ble, this  must  be  palliative.  During  the  time  that  deglutition  still 
brings  liquid  food  into  the  stomach,  the  sufferer  must  be  carefully  fed 
on  highly  nutritious  liquid  diet — liquid  eggs  and  wine,  as  described  in 
the  diet  of  gastritis,  beef -tea,  soups  of  fluid  potato  or  pea  puree  in 
bouillon,  lyCube-Rosenthal  beef-solution,  von  Mehring's  "Kraft" 
chocolate,  egg-nog.  When  pain  was  great,  I  have  found  that  chloral 
hydrate  (15  grains,  three  times  daily)  not  only  relieved  it,  but  acted 
as  a  local  disinfectant  in  the  diverticulum  above  the  stenosis.  Boas 
recommends  iodid  of  potassium  in  doses  of  15  grams,  three  times 
daily,  as  aiding  in  keeping  the  esophagus  from  closing  up  as  soon  as  it 
would  otherwise.  Arsenic  is  said  to  effect  the  same  prolonged  per- 
meability. I  have  had  no  success  with  these  drugs  in  my  cases.  In 
one  case  I  succeeded  in  keeping  the  esophagus  open  for  six  months  by 
intubating  with  an  inelastic  tube  four  inches  long  and  as  wide  as  an 
ordinary  Ewald  tube.  The  tube  was  removed  every  ten  days  and 
replaced.  Patient  lost  no  weight  in  those  six  months,  but  even  gained. 
Death  was  caused  by  aspiration  pneumonia,  during  a  period  in  which 
the  tube  was  left  out  in  order  to  wrest  the  esophagus  froin  the  stout 


SIGNS    IN    CARCINOMA   OF   THE    BODY   OF    STOMACH,  569 

cord  by  which  the  tube  was  connected  with  the  mouth,  and  which  was 
usually  tied  around  the  patient's  neck. 

When  deglutition  is  impossible,  the  only  thing  left  to  be  done  is 
gastrostomy.  If  the  patient  can  be  persuaded  to  undergo  this  opera- 
tion, it  should  be  done  before  marasmus  proceeds  too  far,  as  it  then 
prolongs  life  and  the  shock  of  the  operation  is  better  borne. 

This  operation  consists  in  making  an  opening  into  the  stomach  for 
the  purpose  of  feeding  the  patient  by  passing  food  directly  into  the 
organ.  F.  Kaiser  (in  Czerny,  "Beitr.  z.  operativ  Chirurg.")  collected 
31  gastrostomies;  of  these,  28  died  from  the  immediate  results  of  the 
operation,  ^esas  ("Archiv  f.  klin.  Chirurg.,"  Bd.  xxxii,  S.  188)  re- 
ported 131  cases  from  literature,  mostly  esophageal  cancers,  which  in 
their  stenosing  effects  are  identical  with  those  of  the  cardia.  Among 
these  only  19.5  per  cent,  recovered  sufficiently  from  the  operation  to 
call  this  a  success. 

Carcinoma  of  the  Body  of  the  Stomach  and  of  the  Pylorus. — 
{Cancer  of  the  Fundus,  Anterior  or  Posterior  Walls,  the  Curvatures,  and 
Pylorus.) 

Subjective  Signs. — i.  Sudden  abrupt  beginning  of  the  disease, 
striking  an  apparently  healthy  organ. 

2.  Loss  of  appetite  in  90  per  cent,  of  cases. 

3.  Aversion  to  meat. 

4.  In  stenosing  pyloric  cancer  there  is  much  thirst. 

5.  Frequent  eructations,  which,  when  there  is  dilatation,  can  be 
very  offensive. 

6.  Pressure  in  the  beginning,,  pain  later  on. 

7.  There  is  frequent  vomiting,  which  is  more  copious  in  pyloric  can- 
cers because  of  the  accumulations  from  the  dilatation. 

Frequently  the  vomit  has  a  coffee-ground  appearance,  and  the 
hemin  test  (referred  to  in  part  i)  proves  the  presence  of  blood.  The 
state  of  the  bowels  is  variable,  but  constipation  occurs  in  75  per  cent. 
The  vomit  contains,  as  a  rule,  no  hydrochloric  acid,  but  excess  of 
lactic  acid  and  Oppler-Boas  bacilli. 

Objective  Signs. — On  inspection,  palpation,  and  percussion  a  tumor 
can  be  made  out  in  at  least  50  per  cent,  of  the  cases. 

Tumors  of  the  pylorus  do  not  move  with  the  respiratory  move- 
ments, unless  attached  to  the  liver ;  tumors  of  the  curvatures  gene- 
rally show  distinct  respiratory  movements. 

Examination  of  Stomach-contents. — The  results  will  be  character- 
istic in  most  cases,  and  evince — 


570  MALIGNANT  TUMORS   OF   THE   STOMACH. 

1 .  Grave  interference  with  the  motility. 

2.  Suppression  of  secretion. 

3.  Reduced  or  absent  albumin  digestion. 

4.  Products  of  stagnation  dependent  upon  these. 

5.  Fragments  of  neoplasm  or  mucosa  showing  characteristics  pre- 
viously described. 

The  disturbances  of  peristalsis  are  due  most  likely  to  a  direct  inva- 
sion of  the  muscularis  by  cancerous  proliferation.  The  simplest  way 
of  testing  the  motor  disturbance  is  to  cleanse  the  stomach  thoroughly 
by  lavage  in  the  evening,  giving  a  test-supper  thereafter  and  examin- 
ing the  following  morning,  when,  normally,  the  stomach  should  be 
empty;  but  in  carcinoma  much  food  and  mucus,  with  absence  of 
hydrochloric  acid  and  presence  of  lactic  acid,  are  found  in  88  per  cent, 
of  the  cases  in  our  experience.  In  carcinomata  that  have  arisen  from 
old  ulcers,  a  secretion  of  hydrochloric  acid  persists  until  the  last  stages 
of  the  disease.  This  assertion  of  Rosenheim's  is  not  always  correct; 
if  the  glandular  layer  is  invaded,  secretion  must  cease,  no  matter 
whether  the  carcinoma  arose  from  an  ulcer  or  not.  The  fact  that  car- 
cinomatous ulcers  do  not  destroy  the  secretion  of  HCl,  as  a  rule  is  due 
to  their  anatomical  location — they  occurring  mostly  in  the  pyloric 
region,  which  does  not  contain  the  oxyntic  cells  in  abundance.  I^ac- 
tic  acid  is  tested  for  by  Uffelmann's  reaction ;  in  carcinoma  there  is  an 
excess  in  from  78  to  90  per  cent,  of  the  cases.  Demonstration  of  the 
long,  base-ball-bat-shaped  Oppler-Boas  bacillus  is,  according  to  Kauf- 
man, Schlesinger,  and  Riegel,  a  very  important  sign.  There  should 
always  be  a  careful  lookout  for  histological  evidences,  such  as  bits  of 
the  growth  in  the  wash-water  and  vomit;  this  clinches  the  diagnosis. 

Secondary  symptoms  are  anemia,  cachexia,  and  edema  of  the  ankles 
in  15  to  20  per  cent,  of  the  cases.  The  urine  contains  excess  of  nitro- 
gen excretion,  indican,  and  peptone.  Latent  cancers  may  occur; 
they  are  very  rarely  observed,  however,  at  the  autopsy. 

Ulcus  Carcinomatosutn. — The  diagnosis  is  made  from  a  history  of 
ulcer,  with  years  of  gastric  pain, — not  a  sudden  and  abrupt  beginning, 
— and  the  presence  of  hydrochloric  acid,  even  hyperacidity.  A  pre- 
vious history  of  hematemesis  and  blood  in  the  stools  points  to  origin 
of  the  carcinoma  from  ulcer.  Simple,  uncomplicated  ulcer  may 
cause  a  tumor-like  thickening,  simulating  cancer ;  here  the  analysis  of 
gastric  contents  may,  in  rare  cases,  even  show  excess  of  lactic  acid, 
owing  to  motor  insufficiency  and  cicatricial  stenosis,  and  the  diagno- 
sis then  becomes  difficult,  as  is  also  the  differential  diagnosis  of  ulcus 


TREJATMENT  OF   GASTRIC   CANCER.  571 

carcinomatosum  from  simple  hypertrophic  stenosis  of  the  pylorus. 
Fortunately,  such  states  without  any  other  important  signs  are  rare. 

Treatment. — There  is  no  successful  medicinal  treatment  for  this 
disease.  Life  may  be  prolonged  by  a  suitable  diet,  as  nutritious  as 
possible  and  adapted  to  the  individual  conditions.  A  highly  nutri- 
tious proteid,  carbohydrate,  and  fatty  diet  should  not  be  interdicted 
so  long  as  the  motility  is  good  and  the  patient's  strength  can  be  up- 
held by  intestinal  digestion.  When  there  is  stagnation  owing  to 
pyloric  obstruction,  the  carbohydrates  and  fats  must  be  diminished. 
The  best  tonic  for  the  stomach  is  daily  lavage,  even  when  there  is  not 
much  stagnation ;  but  when  the  latter  is  marked  and  accompanied  by 
fermentation,  antiseptics  may  advantageously  be  added — such  as 
boric  acid,  20  to  30  :  1000  H2O;  salicylic  acid,  3  :  1000  HjO;  sodium 
benzoate,  10  to  30  :  1000  HjO;  resorcin,  10  to  30  :  1000  H2O;  thymol, 
5  :  1000  H2O;  lysol,  I  to  2  :  1000  H2O;  hydrochloric  acid,  4to  5  :  1000 
H2O.  It  is  always  well  to  get  the  stomach  clean  by  simply  using 
warm  salt  solution,  and  to  finish  the  lavage  by  a  last  irrigation  with 
one  of  the  disinfectants,  of  which  we  prefer  hydrochloric  acid. 

A  tonic  which  has  been  serviceable  in  my  experience  and  which  will 
arouse  appetite  and  promote  digestion  in  the  invaded  organ,  if  this  is 
at  all  possible,  is  the  following : 

R  ■     Extract,  condurango, 45-0      c.c.         f^xij 


Strychnin,   sulph., 0.021  c.c.  gr. 


-U 


Acid,  hydrochloric,  dil., 12.0      c.c.         f^iij 

Elixir  gentianpe, .      q.  s.  180.0      c.c.  f5vj.  M. 

SiG. — Take  one  tablespoonful  in  two  ounces  of  water,  after  meals,  through  a  tube. 

When  there  is  much  anemia,  the  following  formulae  have  my  pref- 
erence in  this  disease  as  well  as  in  ulcer : 

R .      Solution  of  iron  and  manganese,    .    .    .  186.60  grams         fs^j 

Liquor  potassi  arsenit., 3.0    grams  ITLxlviij.       M. 

SiG. — One  tablespoonful  three  times  daily. 

Or— 

R.      Strychnin,  sulph. , 0.02  gram  gr.  yC 

Elix.  gentian,  cum  ferri  chloridi,  .  q.  s.  186.60  grams  5VJ.  M. 

SiG. — One  tablespoonful  three  times  daily. 

Constipation  is  best  met  by  large  colon  irrigations  or  with  the  fluid 
extract  or  active  syrup  of  cascara  sagrada  (Clinton) . 

Diarrhea  must  be  met  by  salol,  bismuth  salicylate,  or  benzonaph- 
thol.    Opiates  are  not  advisable  for  this  symptom  unless  there  is  pain. 

For  pain  hot  external  cataplasms  and  20  to  30  drops  of  compound 


572  MALIGNANT   TUMORS    OF   THE    STOMACH. 

spirit  of  ether  should  be  first  tried.  If  severe,  codein  (gr.  ^),  extract, 
belladonnae  (gr.  ^),  in  f5j  of  peppermint  water,  generally  relieves  it, 
and  may  be  repeated  if  requisite.  The  pain  is  rarely  so  intense  as  to 
require  hypodermic  injections  of  morphin.  L-avage  systematically 
and  scientifically  employed  seems  to  prevent  pain;  it  certainly  pro- 
longs life,  and  sometimes  apparently  works  wonders  for  these  patients. 

For  the  diet  in  gastric  carcinoma  we  refer  to  the  chapter  on 
Dietetics,  pages  205  and  242. 

Fifty  grams  of  rich  milk  or  a  glass  of  tokay,  a  few  crackers,  and 
chocolate  are  permissible  foods;  also  young  pigeon,  partridge,  and 
prairie-hen.  If  the  motility  is  good,  one  must  not  be  too  severe  on 
the  patient's  desire  for  food ;  many  cases  can  live  and  gain  strength 
on  an  ordinary  nourishing  diet  when  it  is  not  retained  too  long  in  the 
stomach ;  under  these  circumstances  mutton  chops  and  broiled  beef- 
steak, finely  minced,  may  be  allowed. 

Surgical  Treatment.— As  already  mentioned,  gastrostomy  is  a  pallia- 
tive operation  for  malignant  tumor  of  the  cardia  and  esophagus,  to 
permit  of  direct  introduction  of  food  by  establishing  an  opening  be- 
tween the  stomach  and  the  abdominal  wall.  In  carcinoma  of  the 
pylorus  another  palliative  operation  is  practised — when  it  is  impossi- 
ble or  inexpedient  to  remove  the  growth — under  the  name  of  gastro- 
enterostomy. This  consists  in  the  establishment  of  a  new  communi- 
cation between  the  stomach  and  the  small  intestine,  thus  allowing  the 
chyme  to  reach  the  intestines  without  passing  the  pylorus.     ? 

The  radical  operations  are  resections  of  the  pylorus  or  excision  of  the 
tumor,  no  matter  where  situated  in  the  stomach.  These  operations 
arecontraindicated  if  metastases  are  detectable  in  other  organs,  by  the 
presence  of  great  anemia  or  cachexia,  by  the  large  size  of  the  tumor, 
or  if  there  are  adhesions  to  other  organs.  The  detailed  descriptions  of 
these  operations  belong  to  text-books  on  abdominal  surgery : 

See  "  Surgery  of  the  Alimentary  Canal,"  by  A.  Ernest  Maylard  ;  P.  Blakis- 
ton's  Son  &  Co.,  Philadelphia,  i8g6. 

"The  Cartwright  Lectures  on  Gastric  Surgery,"  by  W.  W.  Keen,  "  Phila. 
Med.  Jour.,"  volume  i,  1898. 

"  Abdominal  Surgery,"  by  J.  Grieg  Smith,  published  by  P.  Blakiston's  Son  & 
Co.,  Philadelphia,  1896. 

"  Surgery  by  American  Authors,"  by  Roswell  Park,  volume  11,  chapter  viii, 
published  by  Lea  Brothers,  Philadelphia. 

"  System  of  Surgery,"  by  Fred.  S.  Dennis,  volume  iv,  page  217. 

"  Abdominal  Surgery,"  by  M.  H.  Richardson  and  Farrar  Cobb. 

"  A  Text-book  of  Abdominal  Surgery,"  by  Skene  Keith  andG.  S.  Keith. 

Frederick  Treves'  "  Manual  of  Operative  Surgery,"  volume  11,  page  405. 


the:  course  to  pursue  in  practice.  573 

Franz  Koenig,  "  Lehrbuch  d.  speciel.  Chirurg.,"  Band  il,  Seite  281. 

Penzoldt  and  Stintzing's  "  Handbuch  d.  speciel.  Therapie,"  volume  iv,  page 
444.  ("  The  Operative  Treatment  of  Gastric  Disorders,"  by  Professor  von 
Heinecke,  Erlangen.) 

The  Course  to  Pursue  in  Practice. — Occurrence  and  Detection. — 
With  the  exception  of  the  cases  that  arise  from  ulcer,  cancer  of  the 
stomach,  as  a  rule,  develops  gradually.  Among  the  phenomena  are 
S3'mptoms  of  more  or  less  severe  dyspepsia,  gradually  ranging  to  the 
most  decided  ones  of  chronic  gastritis,  which,  almost  without  excep- 
tion, accompany  every  carcinoma  of  the  stomach.  Therein  lies  a 
great  hindrance  to  timely  detection.  If,  however, — and  this  espe- 
cially in  older  individuals, — the  symptoms  of  chronic  gastritis  appear 
without  any  distinct  cause,  and  in  a  stomach  previously  entirely 
sound,  and  get  worse  constantly,  even  with  a  mild  diet,  and  are  in- 
creased by  pains  and  vomiting  even  before  food  is  taken  (with  a  je- 
june stomach),  so  that  in  a  few  weeks  rapid  emaciation,  with  an  extra- 
ordinary sallow  complexion,  become  pronounced  features,  carcinoma 
of  the  stomach  should  be  suspected. 

What  are  the  characteristics  and  most  important  diagnostic  signs  of 
gastric  carcinoma?  Examination  with  the  stomach-tube  is  to  be 
made,  and  the  reaction  for  free  acid  in  the  contents  of  the  stomach 
which  have  been  brought  up  one  hour  after  the  test-breakfast  is  to  be 
tried.  In  any  case  the  treatment  with  lavage  is  to  be  instituted,  and 
with  it  the  most  frequent  repetition  of  the  test  for  free  acid.  In  this 
connection  it  is  well  to  make  examination  of  the  juices  after  several 
test-rheals,  and  eventually  with  means  stimulating  the  secretion  of 
acids  (orexin) ;  but,  of  course,  always  at  a  time  when,  under  normal 
circumstances,  free  acid  ought  to  be  present.  Protracted  absence  of 
free  hydrochloric  acid,  even  though  it  may  occur  in  other  diseases  of 
the  stomach,  speaks,  in  the  method  of  procedure  indicated,  with  great 
probability  for  cancer,  since  in  more  than  ninety  per  cent,  of  the  cases 
HCl  was  found  absent.  Frequent  presence  of  hydrochloric  acid 
argues  against  cancer.  Repeated  examination  with  the  tube  brings 
us  other  signs  of  carcinoma,  which  by  other  observations  are  not— or, 
at  any  rate,  not  so  easily — obtained.  Occasionally  a  particle  of  the 
cancer  is  found  in  the  vomited  masses,  and  the  diagnosis  is  made  sure. 
This  may  happen  more  easily  with  lavage  in  the  wash-water  from  car- 
cinoma of  the  cardia,  when  it  may  also  be  found  in  the  eye  of  the  tube. 
During  methodical  lavage,  coffee-ground  vomit  is  seen  earlier  and 
more  frequently  than  if  we  depend  upon  the  vomiting.     In  the  latter 


574  MALIGNANT  TUMORS   OF   THE)   STOMACH. 

case  it  is  often  poured  away  before  the  physician  gets  a  chance  to  ex- 
amine it.  In  case  of  carcinoma  one  does  not  need  to  fear  hemorrhage 
in  using  the  tube,  provided  it  is  done  carefully.  Finally,  one  may  also 
use  the  contents  of  the  stomach  obtained  with  the  tube  for  the  quan- 
titative and  qualitative  determination  of  the  lactic  acid. 

An  approximately  simple  method  for  this  purpose  has  been  recently 
published  by  H.  Strauss,  of  Riegel's  Klinik  ("Berl.  klin.  Wochen- 
schr.,"  1 895,  No.  37).  Excess  of  lactic  acid  has  been  found  in  eighty- 
two  per  cent,  of  my  cases.  It  is  true  that  it  has  also  been  shown  to 
exist  with  gastritis  and  hypertrophic  benign  stenosis  of  the  pylorus, 
which  somewhat  diminishes  its  value.  It  is  not  an  early  sign  in  this 
disease.  But  still,  as  it  appears  at  present,  in  connection  with  other 
signs  it  is  valuable  for  the  diagnosis,  even  though  its  absence  does  not 
argue  against  carcinoma  and  was  especially  observed  in  carcinomat- 
ous ulcer.  It  will  therefore  be  possible  in  many  cases  to  fix  the  diag- 
nosis with  a  great  degree  of  probability,  even  before  a  tumor  is  pal- 
pable, when  elderly  persons  previously  sound  grow  rapidly  worse  in 
spite  of  suitable  treatment,  and  when  cachectic  symptoms  appear 
quickly,  when  the  absence  of  free  hydrochloric  acid  continues,  or 
when  there  is  vomiting  of  coffee-ground  masses.  Since,  ordinarily, 
the  tumor  can  only  be  felt  when  the  cancer  has  reached  a  certain  size 
and  lies  in  an  especially  favorable  position,  the  diagnosis  by  recogni- 
tion of  a  tumor  is  generally  no  longer  an  early  diagnosis.  The  exami- 
nation in  chloroform  narcosis  must  be  brought  in  at  a  comparatively 
early  date  to  facilitate  palpation,  and  with  a  sufficient  degree  of  insen- 
sibility it  will  indeed  very  much  facilitate  the  detection.  Distention 
with  air  through  the  stomach-tube  renders  a  tumor  at  the  front  wall 
or  at  the  pylorus  more  distinctly  recognizable,  and  gives  information 
concerning  the  size  of  the  stomach.  Distention  of  the  intestine  in 
narcosis  by  means  of  air  is  also  brought  in  as  an  aid  to  the  diagnosis. 
If  it  is  not  possible  to  feel  a  tumor,  and  if,  in  spite  of  this,  one  is  con- 
vinced that  a  neoplasm  does  exist,  one  should  propose  an  exploratory 
incision,  with  eventual  further  operative  procedures  if  the  prospects 
warrant  immediate  good  results.  If  carcinoma  should  follow  appar- 
ently in  the  course  of  gastritis  or  ulcer,  the  diagnosis  becomes  more 
difficult  than  if  it  is  developed  in  an  apparently  healthy  stomach,  for 
then  the  symptomatology,  the  state  of  the  secretions,  and  the  proof 
of  the  presence  of  lactic  acid  or  hemorrhage  are  of  much  less  value. 
Then  the  diagnosis  requires  the  greatest  circumspection.  Since  the 
detailed  description  of  all  the  possibilities  does  not  suit  the  compass 


DIET   FOR   GASTRIC    CARCINOMA.  575 

of  the  work,  we  will  here  only  refer  again  to  the  fact  that,  with  rapidly 
increasing  emaciation  of  the  patients,  the  physician  must  not  rest 
until  he  has  found  the  causes  in  a  carcinoma,  or  in  another  factor,  such 
as  stenosis  of  the  pylorus.  In  all  chronic  cases  with  the  chemical  and 
physical  signs  described,  exploratory  laparotomy  is  urged  if  improve- 
ment does  not  follow  in  three  weeks  of  appropriate  treatment.  In 
cases  in  which  the  carcinoma  causes  no  symptoms,  or  only  very  inde- 
finite ones  as  regards  the  stomach  (for  instance,  in  the  case  of  people 
advanced  in  age),  the  diagnosis  is,  of  course,  impossible,  and  active 
treatment  not  so  important.  If  there  is  a  palpable  tumor  in  the  re- 
gion of  the  stomach,  we  have  the  problem  of  determining  that  the 
same  is  really  a  new  formation  belonging  to  the  stomach.  From  the 
therapeutic  standpoint,  one  is  to  avoid  confounding  it  with  tumors 
which  either  need  not  be  or  can  not  be  operated.  Among  the  former 
are  to  be  mentioned  the  normal  head  of  the  pancreas,  which  with 
severe  emaciation  might  be  mistaken  for  a  carcinoma;  lymphatic 
glands,  which  are  felt  as  small  smooth  nodules  alongside  of  the  spinal 
column,  and  may  be  quite  harmless  (Leube) ;  tumor  of  the  spleen, 
which  can  not  be  grasped  from  above;  movable  kidney,  which  is 
smooth,  and  which  gives  the  kidney  shape.  Of  the  nonoperable 
tumors,  or  only  exceptionally  operable,  we  should  exclude  cancer  of 
the  liver,  which,  without  the  characteristic  gastric  symptoms  of  the 
stomach,  causes  the  liver  to  appear  enlarged  and  much  distended,  or 
causes  nodules  to  appear  on  the  palpable  lower  edge  (see  the  extension 
of  the  cancer  from  the  stomach  to  the  liver).  Gall-bladder  and  omen- 
tal carcinomata  are  chiefly  to  be  excluded  from  diagnosis  by  the  ab- 
sence of  the  conspicuous  stomach  symptoms,  and  the  latter  by  the 
want  of  respiratory  movability  and  by  the  presence,  generally,  of 
ascites.  Carcinoma  of  the  mesenteric  glands  is,  under  some  circum- 
stances, not  to  be  distinguished  from  that  of  the  stomach.  Penzoldt 
recently  observed  a  case  which  had,  in  addition,  violent  hematemesis 
and  stomach  symptoms.  The  differential  diagnostic  points  from 
tumors  of  the  duodenum,  colon,  and  neighboring  organs  have  already 
been  considered  (pp.  557  to  559). 

DIET  FOR  GASTRIC  CARCINOMA.— (7?^.f^«/^^zV;/.) 
8  A.  M. — One  cup  of  tea  with  milk  or  a  farinaceous  soup,  eventually  with  a 

little  wheat  bread. 
10  A.M. — Toast,  sardels,  caviar,  perhaps  also  oysters,  with  good  claret,  sherry, 

or  Maderia. 
I  p.  M. — Bouillon   or  soup  (flour,  rice,  sugar,  and   tapioca   soups),  eventually 
.^8 


576  MALIGNANT   TUMORS    OF    THE    STOMACH. 

with  addition  of  peptone,  or  Leube-Rosenthal's  meat-solution.  White 
meat  or  game,  or  beefsteak  from  finely  scraped  beef,  or  jellies  with  gravy, 
or  calves-feet.  Vegetables.  Potato  puree,  finely  chopped  spinach,  well 
cooked  asparagus. 

Stews  :  Stewed  apples,  pears,  prunes  (without  hulls). 
Drinks  :  Red  wine,  water  with  cognac. 
4  p,  M. — Meat  peptone,  chocolate  or  cocoa  with  cakes. 
7  p.  M. — Bouillon  and  soup  from  leguminous  flour. 

For  further  diet  for  gastric  carcinoma  see  chapter  on  Dietetics. 

Treaiment  of  Loss  of  Appetite. — Of  the  so-called  stomachic  remedies, 
condurango  is  useful  in  this  disease.  We  prefer  the  officinal  fluid  ex- 
tract of  condurango.  The  other  stomachics  and  bitter  tonics  used 
are  the  tinctures  of  calumbo,  gentian,  cinchona,  etc. ;  likewise  hydro- 
chloric acid,  which,  however,  does  not  always  agree  with  the  patient. 
Orexin  generally  has  no  effect,  but  an  attempt  with  0.2  to  0.3  gm.  of 
orexin  basicum  should  be  made.  Also,  lavages  of  the  stomach  with 
decoctions  of  hops  and  quassia  wood,  according  to  Kussmaul  and 
Kleiner,  may  be  used  with  advantage.  Washing  the  stomach  re- 
mains the  best  means  for  exciting  the  appetite. 

Treatment  of  Vomiting. — Against  vomiting  we  recommend:  Small 
quantities  of  ice,  ice-cold  water  containing  carbonic  acid  or  cham- 
pagne, a  few  drops  of  chloroform,  tincture  of  iodin,  creasote,  morphin 
subcutaneously  or  as  a  suppositor}",  cold  bandages  on  the  epigas- 
trium. If  it  is  a  consequence  of  stagnation  of  foods  in  the  stomach, 
lavage  is  the  most  efficacious  treatment.  If  the  vomited  matter  has 
a  foul  smell,  and  foul  belching  is  present,  one  may  add  thymol  (0.5 
per  cent.),  boric  acid  (2  to  3  per  cent.),  salicyhc  acid,  resorcin,  chloro- 
form (0.5  per  cent.),  to  the  wash-water.  The  treatment  of  hemor- 
rhages is  the  same  as  for  gastric  ulcer. 

Treatment  of  the  Pain. — Steam  vapor,  bandages,  and  poultices,  hot 
cloths,  or  plates  have  only  a  temporary  success.  If  the  pains  are  ver}' 
violent,  one  can  not  avoid  the  subcutaneous  injection  of  morphin,  but 
care  must  be  exercised  to  avoid  starting  the  morphin  habit. 

Treatment  of  Constipation. — This  ver)'  frequent  and  troublesome 
symptom  must  be  eliminated,  if  possible,  by  large  colon  irrigations 
(one  liter),  by  injections  of  water  with  the  addition  of  soap,  turpen- 
tine, castor  oil,  etc.,  which  increase  their  effect,  or  by  the  injection  of 
glycerin.  Only  when  this  is  of  no  avail  must  recourse  be  had  to  the 
vegetable  purgatives — e.  g.,  Extr.  aloe,  Extr.  rhei  comp.,  aa  3.0;  adde 
Succ.  liq.,  q.  s.  ft.  pil.  30.  M.  One  or  two  pills  at  bedtime.  Saline 
purgatives  are  justly  objected  to,  since  they  weaken  the  patient  to  a 


LITERATURE    ON    CANCER   OF    THE    STOMACH.  577 

remarkable  degree.  For  the  same  reason  Penzoldt,  Ewald,  and  Le- 
bert  declare  that  drinking  cures  at  Carlsbad  and  other  saline  springs 
are  not  advisable.  This  prohibition  is  generally  very  hard  for  those 
patients  who  have  placed  all  their  hope  on  a  sojourn  at  the  springs. 
The  advice  of  Lebert  (quoted  by  Ewald),  to  let  them  drink  small 
quantities  of  the  mineral  water  at  home,  is  very  practical,  for  gener- 
ally it  is  without  success,  and  the  patient  will  then  willingly  give  up  a 
trip  to  the  springs.  If  the  constipation  is  due  to  stenosis  of  the  pylo- 
rus, medicines  by  the  mouth  are  useless.  So  the  treatment,  briefly, 
is  lavage,  tonics,  rest,  the  most  highly  concentrated  and  nutritious 
food,  whenever  it  is  too  late  or  impossible  to  operate. 

Prognosis. — If  the  diagnosis  can  be  made  early,  and  operative 
treatment  gives  fair  prospects  of  immediate  good  results,  there  is,  as 
we  have  seen  from  the  statistics  given  in  the  chapter  on  Surgical 
Operations  (p.  349),  some  hope  of  prolonging  life.  But  if  an  opera- 
tive interference  is  impossible  (see  the  contraindications,  p.  367)  or 
refused,  the  disease  must  prove  fatal.  Careful  dietetic  and  mechani- 
cal treatment  may,  in  individual  cases,  prolong  life  for  several  months. 
In  cancerous  neoplasms  that  do  not  affect  the  orifices  the  immediate 
danger  is  not  so  great.  I  have  reported  a  case  in  which  a  positive 
diagnosis  of  malignant  tumor  could  be  made  from  a  cancer  particle 
that  came  up  in  the  wash-water  and  in  which  a  tumor  was  diagnosed 
by  Da  Costa  and  Musser  sixteen  months  before  the  author  examined 
the  patient.  This  patient  lived  two  years  and  two  months  after  the 
tumor  was  first  recognized. 


LITERATURE  ON  CANCER  OF  THE  STOMACH. 

1.  Aaron,  C.  A.,  "  The  Early  Diagnosis  of  Cancer  of  the  Stomach,"  "  Canada 
Lancet,"  1897-98,  xxx,  395-398. 

2.  Acker,  "  Zur  Pathogenese  der  Geschwulstmetastasen,"  "  Deutsche  Archiv 
f.  kUn.  Med.,"  xi. 

3.  Aisberg,  "  Casuistik  zur  Chirurgie  der  Magencarcinoms  "  ;  "  Drei  Falle 
von  Gastro-enterostomie,  im  dritten  Verlangerung  des  Lebens  um  drei  Jahre 
und  fiinf  Monate,"  "  Miinch.  med.  Wochenschr.,"  No.  50  und  51,  1896. 

4.  Arnold,  J.,  "  Ueber  Theilungsvorgange  in  den  Wanderzellen  :  ihre  pro- 
gressive u.  regressive  Metamorphose,"  "  Archiv  f,  mikr.  Anatomie,"  xxx,  1887. 

5.  Arnold,  J.  P.,  "Colloid  Cancer  of  the  Stomach,"  "  Proc.  Path.  Soc," 
Phila.,  i897-'98,  i,  305. 

6.  Badaloni,  N.,  "Del  cancero  dello  stomaco,"  "Gazz.  de  osp.  Milano," 
1897,  XVIII,  705-740. 

7.  Bazy,  "  Cancer  de  I'estomac,  gastro-enterostomie;  avec  .le  bouton  de 
Murphy,"  "  Bull,  de  la  Soc.  de  chirg.,"  Xix,  1896. 


578  MALIGNANT  TUMORS   OP  THE   STOMACH. 

8.  Benedict,  A,  L.,  "  Some  so-called  Diagnostic  Points  of  Gastric  Carci- 
noma," "  Int.  Med.  Magazine,"  Phila.,  iSgy-'gS,  vi. 

9.  Billroth,  "Wiener  klin.  Wochenschr.,"  1891,  No.  34. 

10.  Boas,  J.,  "  Ueber  das  Vorkommen  von  Milchsaure  im  gesunden  und 
kranken  Magen,  nebst  Bemerkungen  zur  Klinik  des  Magencarcinoms,"  "  Zeit- 
schrift  f.  klin.  Med.,"  Bd.  xxv,  1894. 

11.  Bousquet,  "  Du  chimisme  gastrique  dans  le  cancer  d'estomac,"  "  These 
de  Paris,"  1896. 

12.  Bosquier,  "  Coexistance  d'une  cirrhose  de  Laennec  et  d'un  cancer  latent 
de  I'estomac,"  "Journal  de  med.  de  Lille,"  18,  i,  1896. 

13.  Brechoteau,  "  Du  phlegmon  peri-ombilical  et  des  fistules  gastro-cutanese 
dans  le  cancer  de  I'estomac,"  "  These  de  Paris." 

14.  Bret,  "Adenopapillare  de  I'estomac,"  "  Soc.  anat.  de  med.  de  Lyon,"  16, 
mars,  1898. 

15.  Brinton,  W.,  "  British  and  Foreign  Medico-Chirurgical  Review,"  Jan- 
uary, 1857. 

16.  Brooks,  H.,  "  A  Case  of  Primary  Multiple  Sarcoma  of  the  Stomach,  Fol- 
lowing Gunshot  Wound,"  "  Med.  News,"  N.  Y.,  1898,  Lxxxii,  pp.  617-626. 

17.  Bryant,  Jos.  D.,  "  The  Wesley  M.  Carpenter  Lecture,"  "  N.  Y.  Med. 
Jour.,"  May  18,  1895. 

18.  Buhre,  B.,  "  Die  Bedeutung  der  Milchsaure  Reaction  fur  die  Diagnose 
des  Magenkrebses,"  "  Hygiea,"  1897,  Heft  i  (Schwedisch). 

19.  Cahn  und  von  Mehring,  "Berl.  klin.  Wochenschr.,"  1885. 

20.  Capello,  P.,  "  A  propositio  di  un  raro  caso  di  mio  sarcoma  cistico 
dello   stomaco,"    "Bull.  d.  s.  Accad.  med.  di   Roma,"    i898-'99,  xxiv,  321- 

342. 

21.  Capps,  J.  A.,  "  Digestion  Leukoc3'tosis  as  an  Aid  in  Diagnosis  of  Cancer 
of  the  Stomach,"  "Boston  Med.  and  Surg.  Jour.,"  1897,  cxxxvii,  468,  i. 

22.  Cardarelli,  "Carcinoma  dello  stomaco  svil  uppato  sulfondo  di  ulcera," 
"  Clin,  mod.,"  Pisa,  1897,  ill,  173. 

23.  Carter,  J.  M.  G.,  "  The  Treatment  of  Carcinoma  of  the  Stomach,"  "  In- 
ternat.  Clin.,"  Phila.,  1897,  ill,  45-50. 

24.  Caussade  et  Renon,  "  Cancer  du  pylore,  suppressive  de  la  function 
pylorique,  atrophic  de  I'estomac,  atrophie  generalisee  de  tours  les  organes," 
"  Presse  med.,"  i  Janvier,  1898. 

25.  Chaine,  "Cancer  du  pylore  sans  hematemese  ni  melaena ;  Cancer  du 
foie,"  "Jour,  de  med.  de  Bordeaux,"  31  Janvier,  1896. 

26.  Chaput,  "  Ulcere  gastrique  avec  degenerescence  cancereuse  au  debut 
presentation  du  malade,"  "  Soc.  med.  des  hop.,"  15  Octobre,  1897. 

27.  Chiaruttini,  E.,  "  Sul  valore  dell  acido  lattico  gastrico  per  la  diagnosi 
di  cancero  dello  stomaco,"  "  Gazz.  d.  osp.  Milano,"  1897,  xviil,  613-616. 

28.  Clarke,  J.  M.,  "  A  Case  of  Cancer  of  the  Pylorus  Presenting  some  Un- 
usual Features,"  "  Lancet,"  London,  1898,  11,  866-868. 

29.  Coley,  "  Amer.  Jour,  of  the  Med.  Sciences,"  1894. 

30.  Comte,  "  N6oplasme  du  pylore,  pyloro-plastic,  gastro-enterostomie," 
"  Soc.  des  sc.  med.  de  Lyon,"  Avril,  1898. 

31.  Cook,  G.  W.,  "  Adeno-carcinoma  of  the  Stomach,"  "  Nat.  Med.  Rev.," 
Wash.,  1898-99,  VIII,  197. 

32.  Coyon,  "  Cancer  du  pylore  avec  generalisation,"  "  Soc.  anat.,"  10  Jnni, 
i8q8. 


LITERATURE   ON   CANCER   OF   THE   STOMACH.  579 

33.  Cuony,  "  Un  cas  de  guerison,  sans  intervention  chirurgicale,  d'une  affec- 
tion cancereuse  de  I'estomac,"  "  Rev.  med.  de  la  Suisse  Rom.,"  Geneve,  1897, 
xvii,  582-586. 

34.  Davison,  C,  "  Carcinoma  of  the  Stomach,"  "  Chicago  Clinic,"  1898,  xi, 
213-216. 

35.  Debove,  "  Societe  med.  des  hopit.,"  November,  1889. 

36.  Deguy,  "  Cancer  latent  de  la  face  posterieuse  de  I'estomac,"  "  Presse 
med.,"  15,  VII,  1896. 

37.  Deguy,  "  Diagnostic  du  cancer  d'estomac,"  "Journal  des  Practice,"  16 
Janvier,  1896. 

38.  Deutschlander,  "  Ueber  die  diagnost.  Bedeutung  des  Magenchemismus 
bei  Carcinoma  ventriculi,"  Dissert.,  Graefewaid,  i895-'96. 

39.  Dieulafoy,  "  Transformation  de  I'ulcere  stomacal  en  cancer  (abstr.)," 
"  Presse  med.,"  Par.,  1897,  li,  286-293. 

40.  Dock,  Geo.,  "  Amer.  Jour,  of  the  Med.  Sciences,"  June,  1897,  p.  655. 

41.  Dock,  Geo.,  "Cancer  of  the  Stomach  in  Early  Life,  and  the  Value  of 
Cells  in  Effusions  in  the  Diagnosis  of  Cancer  of  the  Serous  Membranes," 
"  Tr.  Ass.  Am.  Physicians,"  Phila.,  1897,  xii,  152-157,  i  pi. 

42.  Dreyer,  "Ueber  das  Magencarcinom,"  Diss.,  Berlin,  1894. 

43.  Ebstein,  "  Ueber  Magenkrebs,"  "  Volkmann's  Sammlung  klin.  Vor- 
trage,"  Nr.  87. 

44.  Eichhorst,  "  Lehrbuch  der  spec.  Pathol,  und  Therapie." 

45.  Eisenlohr,  "  Deutsches  Archiv  f.  klin.  Med.,"  1895. 

46.  Ekehorn,  G.,  "Some  Further  Cases  of  Cancer  of  the  Stomach,  with 
Special  Reference  to  the  Lactic  Reaction,"  "  Upsala  Lakaref.  Forh,"  i896-'97, 
N.  F.,  II,  332-339. 

47.  Ely,  J.  S.,  "  A  Study  of  Metastat.  Carcinoma  of  the  Stomach,"  "Ameri- 
can Journal,"  June,  1890. 

48.  Emmerich,  "  Deutsche  med.  Wochenschr.,"  1895. 

49.  Ewald,  "  Krebs  der  Cardia  Metastase  im  rechten  Leberlappen  ;  Gastros- 
tomies" "  Deutsche  med.  Wochenschr.,"  1889,  Nr.  23. 

50.  Falk,  Fritz,  "  Ueber  einen  Fall  von  Netz  echinokokkus  mit  Magencar- 
cinom," Dissert.,  Wiirzburg,  j896-'97. 

51.  Feirtag,  "  Ueber  das  Verhalten  des  gesunden  und  kranken  Magens  be- 
ziichlich  der  Milchsaurebildung  wahrend  der  Kohlenhydratverdauung," 
Jurjew-Dorpat,  1894. 

52.  Fenwick,  N.  S.,  "  The  Early  Diagnosis  of  Cancer  of  the  Stomach," 
"  Edin.  Med.  Jour.,"  1898,  N.  S.  in,  254-260. 

53.  Fick,  W.,  "  Ein  Endotheliom  und  ein  Carcinom  des  Magens," 
"  Deutsche  Zeitschr.  f.  Chir.,"  Leipz.,  i898,XLViii. 

54.  Fischl,  "  Die  Gastritis  bei  Carcinom  des  Magens,"  "  Prager  Zeitschr.  f. 
Heilkunde,"  1891. 

55.  Fitz  (R.  H.),  Conant  (W.  M.),  and  Porter  (C.  B.),  "  Successful  Resection 
of  the  Pylorus  for  Cancer,"  "  Bost.  Med.  and  Surg.  Jour.,"  October  27,  1898. 

56.  Flatow,  "  Ueber  die  Entwickelung  des  Magenkrebses  aus  Narben  des 
runden-Magengeschwurs,"  Diss.,  Miinchen,  1887. 

57.  Forneau,  Richard,  "Ein  Beitrag  zur  Aetiologie  des  Magencarcinoms," 
Dissert.,  Kiel,  i896-'97. 

58.  Fotheringham,  "  Carcinoma  of  the  Stomach,"  "  Canad.  Pract.," 
Toronto,  1897,  xxii,  920-922. 


580  MALIGNANT   TUMORS    OF   THE    STOMACH. 

59.  Fox,  "The  Diseases  of  the  Stomach,"  London,  1872,  p.  184. 

60.  Frenoy,  "  Des  taux  cancers  de  I'estomac,"  "These  de  Paris,"  1897. 

61.  Friedenwald,  J.,  "  Latent  Cancer  of  the  Stomach,"  "  Maryland  Med. 
Jour.,"  Baltimore,  1898,  xxxix. 

62.  Friedreich,  "  Ein    Fall   von    Magenkrebs,"  "  Berl.  klin.  Wochenschr.," 

1874. 

63.  Fussell,  M.  H.,  "  Carcinoma  of  the  Stomach,"  "  Tr.  Path.  Soc,"  Phila., 
1898,  XVIII,  p.  46. 

64.  Gauthier,  "  De  I'etat  du  coeur  dans  le  cancer  primitif  d'estomac,"  "  These 
de  Lyon,"  1896. 

65.  Gockel,  M.,  "  Ueber  die  traumatische  Entstehung  des  Carcinoms,  mit 
besonderer  Beriicksichtigung  des  Intestinaltractus,"  "  Archiv  d.  Verd.- 
Krankh.,"  Bd.  11. 

66.  Godhardt-Danhieux,  "  Sur  le  diagnostic  du  cancer  de  I'estomac,"  Poly- 
clin.,  Brux.,  1897,  VI,  39-48. 

67.  Golding-Bird,  "  Contributions  to  the  Chemical  Pathology  of  Some  Forms 
of  Morbid  Indigestion,"  "  London  Med.  Gazette,"  1842,  p.  391. 

68.  Gordon,  A.,  "  The  Semeiotic  Value  of  the  Different  Symptoms  in  Can- 
cer of  the  Stomach,"  "  N.  Y.  Med.  Jour.,"  1898,  LXViii. 

69.  Griesinger,  "Archiv  f.  phys.  Heilkunde,"  1854,  p.  528. 

70.  Guinard,  Urbain,  "  Cancer  du  pylore  sans  troubles  gastriques,  Pylorec- 
tomie,  Guerison,"  Soc.  Anat.,  10  vols.,  1897. 

71.  Haberlin,  "Ueber  neue  diagnostische  Hiilfsmittel  bei  Magenkrebs," 
"  Deutsches  Archiv  f.  klin.  Med.,"  1889,  Bd,  xlv. 

72.  Hamilton,  H.  J.,  "  Carcinoma  of  the  Stomach  with  Subcutaneous  Metas- 
tasis," "  Canad.  Pract.,"  Toronto,  1898,  xxiii. 

73.  Hampeln,  P.,  "  Zeitschr.  f.  klin.  Med.,"  Bd.  viii,  p.  232. 

74.  Hanau,  "  Erfolgreiche  experimentelle  Uebertragung  von  Carcinom," 
"  Fortschritte  der  Med.,"  1889,  Nr.  9. 

75.  Hanot,  "  Sur  une  forme  septicemique  du  cancer  de  I'estomac,"  "Archiv 
gen.  de  Med.,"  Sept.,  1892. 

76.  Hauser,  "  Das  chronische  Magengeschwiir,  sein  Vernarbungs-Process 
und  die  Beziehung  zur  Entwickelung  des  Magencarcinoms,"  Leipzig,  1883. 

']'].  Hauser,  "  Das  Cylinderepithelcarcinom  des  Magens  und  des  Dick- 
darms,"  Jena,  1890. 

78.  Hayem,  G.,  "  Forme  anemiquedu  cancer  de  I'estomac,"  "  Pressemed.," 
Paris,  1898,  II. 

79.  Hayem,  "  Diagnostic  du  cancer  du  pylore,"  "  Med.  moderne,"  li  Juni, 
1898. 

80.  Hechler,  F.  H.,  "  Ueber  den  diagnostischen  Wert  der  Lymphdriisen- 
schwellung  in  den  Oberschliisselbeingruben,  bes.  in  der  linken  bei  Magen- 
krebs," Dissert.,  Berlin,  i896-'97. 

81.  Heinemann,  "  Virchow's  Archiv,"  vol.  lviii,  p.  180. 

82.  Henry,  Fred  P.,  "  The  Diagnostic  Value  of  the  Blood  Count  in  Latent 
Gastric  Cancer,"  "Archiv  der  Verd.-Krankh.,"  April  i,  1898. 

83.  Hensen,  H.,  "Ueber  einen  Befund  von  Infusiorien  im  Mageninhalt  bei 
Carcinoma  ventriculi,"   "  Deutsches  Archiv  f.  klin.  Med.,"  Leipzig,  1897,  LIX. 

84.  Herard,  "  Formes  septiques  du  cancer  I'estomac,"  These  de  Paris,  1896. 

85.  Heresco,  "  Hernie  ombilicale  avec  phenomenes  d'6stranglement,  cancer 
du  pylore,  gastro-enterostomie,"  Soc.  Anat.,  Paris,  6,  in,  1897. 


LITERATURE   ON   CANCER   OF   THE   STOMACH.  58 1 

86.  Hiltermann,  "  Ueber  Metastase  eines  Gallertkrebses  des  Magens  in  die 
Lungen,"  Dissert.,  Wiirzburg,  i895-'96. 

87.  Hirsch,  "  Handbuch  der  histologischgeographischen  Pathologie," 
Erlangen,  i862-'64. 

88.  Hirtz  et  Luys,  "  Ascite  chyliforme  an  cours  d'un  cancer  de  I'estomac," 
Soc.  med.  des  hop.,  8  Octobre,  1897. 

89.  Hofmann,  A.,  "  Die  Verdauungsleukocytose  bei  Carcinoma  ventriculi," 
"  Zeitschr.  f.  klin.  Med.,"  Berlin,  1897,  xxxiii,  pp.  460-475. 

90.  Honigmann  und  v.  Noorden,  "Ueber  das  Verhalten  der  Salzsaure  in 
carcinomalosen  Magen,"  "  Zeitschr.  f.  klin.  Med.,"  xiii. 

91.  Hosslin,  v.,  "Ueber  den  Einfluss  ungeniigender  Ernahrung  auf  die  Be- 
schaffenheit  des  Blutes,"  "  Miinch.  med.  Wochenschr,"  1890,  Nos.  38  and  39. 

92.  Hiibner,  "  Untersuchungen  iiber  44  Falle  von  Magencarcinom,  mit 
besonderer  Beriicksichtigung  der  Milchsaurefrage,"  Dissert.,  Rostock,  i895-'96. 

93.  Hiiltl,  H.,  "  Ein  Fall  von  Gastro-enterostomie  bei  Carcinoma  pylori," 
Gyogyaszat,  Nr,  i,  1898. 

94.  Israel,  O.,  "  Magenkrebs  mit  ungewohnlicher  secundarer  Ausbreitung 
in  Darmkanal,  Recurrenslahmung  und  Bemerkung  iiber  kiinstliche  Beleuch- 
tung,"  "  Berl.  klin.  Wochenschr,"  Nr.  4,  1898. 

95.  Ivanhoff,  M.  N.,  "  Malignant  Tumor  of  the  Stomach  Treated  Success- 
fully by  the  Alkaloid  of  Chelidoniun  majus,"   "  Med.  Obozr.,"  Mosk.,  1898,  L. 

96.  Jacobs,  "  Ein  Fall  von  Magen-  und  Ovarialkrebs  mit  gleichzeitiger 
Tuberkulose,"  Dissert.,  Kiel,  i895-'96. 

97.  Jez,  v.,  "Ueber  die  Blutuntersuchung  bei  Magenerkrankungen,  beson- 
ders  bei  Ulcus  rotundum  und  Carcinoma  ventriculi,"  "  Wiener  med.  Wochen- 
schr.," 1898,  XLViii,  pp.  633-693. 

98.  Johnston,  J.  A.,  "  Specimen  of  Carcinoma  of  the  Stomach,"  "Cincin. 
Lancet-Clinic,"  1897,  N.  S.,  xxxviii,  p.  552, 

99.  Johnston,  G.  W.,  and  Stewart,  A.,  "  The  Value  of  Certain  Chemical  and 
Microscopical  Procedures  in  the  Diagnosis  of  Cancer  of  the  Stomach,"  "  Nat. 
Med.- Rev.,"  Wash.,  1897-98,  vii. 

100.  Kaufmann,  E.,  "  Ein  seltenes  Praparat  von  Magencarcinom,"  "Jahresb. 
d.  schles.  Gesellsch.  f.  vaterl.  Cult.,"  1896,  Breslau,  1897,  LXXiv,  i  Abt.,  Med. 
Sect.,  152. 

loi.  Katzenellenbogen,  "  Beitrage  zur  Statistik  des  Magencarcinoms," 
Inaug.  Diss.,  Jena,  1878. 

102.  Kellogg,  J.  H.,  "Cancer  of  the  Stomach,'  "  Tr.  Mich.  Med.  Soc," 
Grand  Rapids,   1897,  xxi. 

103.  Kelynack,  J.  N.,  "On  the  Occurence  of  a  Cancerous  Development  in 
Simple  Ulcer  of  the  Stomach,"  "The  British  Med.  Jour.,"  18,  i,  1897. 

10^.  Klebs,  "  AUgemeine  Pathologie  ":  "  Ueber  das  Wesen  und  die  Erken- 
nung  der  Carcinombildung,"  "  Deutsche  med.  Wochenschr.,"  1890. 

105.  Klemperer,  "  Ueber  den  Stoffwechsel  und  das  Koma  der  Krebs- 
kranken,"  "  Berl.  klin.  Wochenschr.,"  1889. 

106.  Koch,  "  Ueber  das  Carcinoma  ventriculi  ex  ulcero  rotundo,"  "  Petersb. 
med.  Wochenschr.,  1894. 

107.  Knickerbocker,  H.  ].,  "  The  Oppler-Boas  Bacilli  in  the  Diagnosis  of 
Gastric  Carcinoma,"  "  Phila.  Med.  Jour.,"  vol.  11,  1898,  p.  1084.- 

108.  Knoll,  "  Ein  Fall  von  Pleuritis  carcinomatosa  bei  primarem  Magen- 
carcinom," Dissert.,  Miinchen,  i895-'96. 


582  MALIGNANT   TUMORS    OF   THE    STOMACH. 

109.  Kraske,  P.,  "  Erfahrungen  iiber  den  Mastdarmkrebs,"  "  Samml.  klin. 
Vortr.,"   N.  F.,  Leipzig,  1897,  Nos.  183,  184  (Chir.,  Nos.  52,  53,  771-851). 

no.  Krukenberg,  "  Ueber  die  diagnostische  Bedeutung  des  Salzsaurenach- 
weises  beim  Magenkrebs,"  Diss.,  Heidelberg,  1888. 

111.  Kulneff,  N.,  "Ueber  basische  Zersetzungs-producte  irn  Magen-  und 
Darminhalt,"  "  Berl.  klin.  Wochenschr.,"  1891,  Nr.  44. 

112.  Von  Kundrad,  R.,  und  Schlesinger,  H.,  "  Zur  Diagnose  der  Verwach- 
sung  zwischen  Pylorustumoren  and  Leber,"  "  Mitt.  a.  d.  Grenzgeb.  Med.  d.  u. 
Chir.,"  Jena,  1897,  11,  727-730. 

113.  Laache,  S.,  "  Die  Anamie,"  Christiania,  1883. 

114.  Lannois  et  Courmont,  "  Note  sur  la  coexistence  des  deux  cancers  primi- 
tifs  du  tube  digestif,"  "  Rev.  de  Med.,"  1894,  Nr.  4. 

115.  Lannois,  "Cancer  simultane  du  pylore  et  des  ovaires,"  "  Soc,  des 
science  med.  de  Lyon,"  Novembre,  1896. 

116.  Laulie,  "  Squirrhe  du  pylore  et  rein  flottant,  pylorectomie  et  gastro-enter- 
ostomie :  Soc.  d.  anat.  et  phys.  de  Bordeaux,"  6  Juni,  1897. 

117.  Lebert,  "Ueber  Magenkrebs,  in  atiologischer  und  pathogenetischer 
Beziehung,"  "  Deutsches  Archiv  f.  klin.  Med.,"  1877,  Bd.  xxix. 

118.  Lepine  cf.  Mouisset,  "  Etude  sur  le  carcinome  de  I'estomac,"  "  Revue 
de  Med.,"  1891. 

119.  Letulle,  "Carcinose  peritoneo-intestinale  secondaire  a  un  cancer  de 
I'estomac,"  "  Soc.  anat.  de  Paris,"  24,  vii,  1896. 

120.  Letulle,  "  Diagnostic  du  cancer  de  I'estomac,"  "  Prov.  med.,"  15,  vii, 
1896. 

121.  Letulle,  "  Cancer  multiples  du  tube  digestif,"  "  Presse  med.,"  19  Mai, 
1896. 

122.  Leyhdecker,  O.,  "  Ueber  einen  Fall  von  Carcinom  des  Ductus  thoracicus 
mit  chylosem  Ascites,"  Inaug.-Diss.,  Heidelberg,  1893,  "  Virchow's  Archiv,'' 
1893,  Bd.  cxxxiv. 

123.  Limbeck,  V.,  "  Grundriss  einer  klinischen  Pathologic  des  Blutes,"  Jena, 
1896. 

124.  Lindh,  A.,  "  Operationen  wegen  Magenkrebs  und  Magengeschwiir," 
"  Verhandl.  der.  Gothenburg,  arztl.  Gesellschaft,  i896-'97,"  Casuistische  Mit- 
theilungen. 

125.  Lyonnet,  "  Linites  cancereuses,  ganglions  troisies,  ascite  chyleuse,  gen- 
eralisation au  coeur,"  "  Lyon  med.,"  28  mar,  1896,  pp.  493-494,  F.  84. 

126.  Lyonnet,  B.,  et  Bonne,  C,  "  Cancer  de  I'estomac;  ouverture  dans  la 
rate,"  "  Prov.  med.  Lyon,"  1897,  xi,  p.  259. 

127.  Macdonald,  G.  C,  "Total  Removal  of  the  Stomach  for  Carcinoma  of 
the  Pylorus;  Recovery,"  "  Journal  of  Amer.  Med.  Assoc,"  Sept.  3,  1898. 

128.  Maillefert,  "  Zur  Lehre  vom  Carcinoma  ventriculi  ex  Ulcere  rotundo," 
Dissert.,  Greifswald,  i895-'96. 

129.  Malkoff,  G.  M.,  "  Apropos  of  a  Case  of  Cancer  in  the  Region  of  the 
Pylorus  of  the  Stomach  Combined  with  Round  Ulcer,"  "  Bolnitsch.  gaz,," 
Botkina,  St.  Petersburg,  1897,  viii,  pp.  434  and  981. 

130.  Malkow,  G.,  "  Ueber  einen  Fall  von  Carcinom  des  Pylorus  mit  Ulcus 
rotundum  combiniert,"  "  Botkina  Krankenhaus  Zeitung,"  25,  26,  1897. 

131.  Martin,  "  Retrecissement  neoplastique  du  pylore,"  "  Journal  de  mede- 
cine,"  Bordeaux,  21  Fevrier,  1897. 

132.  Matieu,  M.,  "  Du  cancer  precocede  I'estomac,"  "  These  de  Lyon,"  1884. 


LITERATURE   ON   CANCER   OF   THE   STOMACH.  583 

133.  Matieu,  M.,  "  Etat  dela  muqueuse  de  I'estomac  dans  le  cancer  de  cet 
organ,"  "Archiv  gen.  de  Med.,"  1889. 

134.  Mathieu,  A.,  "  Etude  sur  trois  cas  de  cancer  succedant  al'ulcere  simple 
de  I'estomac,"  "  Bull,  et  mem.  Soc.  med.  d.  hop  de  Par.,"  1897,  3.  s.,  xiv,  pp. 
1082-1098. 

135.  Mathieu,  A.,  et  Lanier,  Nathan,  "  Cancer  du  canal  thoracique,  consec- 
utif  a  un  cancer  de  I'estomac,"  "Bull,  et  mem.  Soc.  med.  d.  hop.  de  Par.," 
1898,3.  s.,  XV,  827-838. 

136.  McGraw,  T.  A.,  "  Pyloric  Cancer,"  "  Phys.  and  Surg.,"  Detroit  and 
Ann  Arbor,  1897,  xix,  pp.  252-256. 

137.  McRae,  T.,  "  Report  on  150  Cases  of  Cancer  of  the  Stomach  in  the 
Medical  Wards  of  the  Johns  Hopkins  Hospital,"  "  Maryland  Med.  Jour.,"  1898, 
XXXIX,  p.  609. 

138.  Menetrier,  "Arch,  de  Physiolog.,"  15  Fevr.,  1888. 

139.  Miiller,  Fr.,  "  Stoffwechseluntersuchungen  bei  Krebskranken,"  "  Zeit- 
schr.  f.  klin.  Med.,"  1889,  xvi. 

140.  Noble,  Wm.  H.,  "  Report  of  an  Operation  for  the  Removal  of  the  Stom- 
ach for  Carcinoma,"  "  N.  Y.  Med.  Jour.,"  July  23,  1898. 

141.  Notthafft,  "  Ueber  die  Entstehung  der  Carcinome,"  "  Deutsches  Archiv 
f.  khn.  Med.,"  Bd.  Liv,  1895. 

142.  Nothmann,  "  Ueber  Strahlennarben  des  Magens  und  Carcinoma  ven- 
triculi,"  Dissert.,  Wiirzburg,  i895-'96. 

143.  Olivvier  et  Halipre,  "  Gastrite  sclereuse  hypertrophique  de  nature  can- 
cereuse,"  "  Normandie  medicale,"  i,  iv,  1898. 

144.  O'Neil,  Wm.,  "A  case  of  Vomiting  Large  Masses  of  Cancerous  Mat- 
ter," "  Lancet,"  London,  3,  x,  1896. 

145.  Pal,  J.,  "Carcinoma  ventriculi ;  Anemia;  Tod,"  "  Jahrb.  d.  Wien.k. 
k.  Krankenanst.,"  1895,  Wien  u.  Leipzig,  1897,1V,  pt.  2,  42. 

146.  Pean,  Doyen,  etc.,  "  Traitement  chirurgical  du  cancer  de  I'estomac," 
X.  Congr.  Fran^.  de  chirurgie,  1897. 

147.  Perret,  "  Cancer  colloide  du  pylore  avec  propagation  aux  ganglions  de 
la  colonne,  au  rein  gauche,  au  cervelet,  etc.,"  "  Soc.  des  science  med.  de  Lyon," 
Avril,  1897. 

148.  PhiUippen,  J.,  "  La  valeux  du  signe  de  Boas  dans  le  diagnostic  du  can- 
cer de  I'estomac,"  "  Clinique,"  Brux.,  1898,  xii,  1-5. 

149.  Pianese,  "  Beitrag  zur  Histologie  und  Aetiologie  des  Carcinoms  " 
(Deutsch  von  Teuscher),  Suppl.  zu  "  Ziegler's  Beitrage,"  Jena,  1899. 

150.  Plitek,  v.,  "Appuntisulla  combinazione  del  carcinoma  con  I'ulcera 
dello  stomaco,"  Morgagni,  Milano,  1897,  xxxix,  53-64. 

151.  Porger,  "  Ein  Fall  von  Carcinoma  ventriculi  durch  Resection  geheilt 
seit  sechs  Jahren  ohne  Recidiv,"  "  Wien.  med.  Wochenschr.,"  No.  36,  1897. 

152.  Poth,  "Ein  Fall  von  beginnenden  Magencarcinom,"  Dissert.,  Mun- 
chen,  i895-'96. 

153.  Quenu,  "Gastro-enterostomie  avec  bouton  de  Murphy  et  pylorectomie 
pour  cancer  de  I'estomac;  mort  16  mos.  apres,"  "Bull.de  la  Soc.  de  chir.," 
XIX,  1897-. 

154.  Rabe,  "  Cancer  du  coeur,  secondaire  a  un  cancer  de  I'estomac,"  Soc. 
anat.,  26  Novembre,  1897. 

155.  Rauzier,  "  De  la  Diminution  de  I'uree  dans  le  cancer,  Hypazoturie  can- 
cereuse,"  "These  de  Montpellier,"  Ref.  in  "Arch,  de  Med.  exp.,"  1890. 


584  MALIGNANT  TUMORS   OF   THE   STOMACH. 

156.  Reineboth,  "  Die  Diagnose  des  Magencarcinoms  aus  Spiilwasser  und 
Erbrochenem,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  LViii,  4. 

157.  Ribbert,  "  Beitrage  zur  Histogenese  des  Carcinoms,"  "  Virchow's 
Archiv,"  Bd.  cxxv. 

158.  Ribbert,  "  Weitere  Beobachtungen  liber  die  Histogenese  des  Carci- 
noms," "  Centralbl.  f.  allg.  Pathologie,"  v,  1894. 

159.  Richardson,  M.  H.,  "  A  Successful  Pylorectomy,  with  Removal  of  a 
Portion  of  the  Pancreas,  for  Cancer  of  the  Pylorus,"  "  Boston  Med.  and  Surg. 
Jour.,"  Aug.  4,  1898. 

160.  Richardson,  M.  H.,  "A  Successful  Gastrectomy  for  Cancer  of  the 
Stomach,"  "  Boston  Med.  and  Surg.  Jour.,"  Oct.  27,  1898. 

161.  Riegel,  "  Ueber  die  therapeutische  Anwendungder  Condurangorinde," 
"Berl.  klin.  Wochenschr.,"  1874. 

162.  Riegel,  "Ueber  den  Werth  der  Condurangorinde  bei  den  Symptomen- 
bild  des  Magencarcinoms,"  "  Berl.  klin.  Wochenschr.,"  1887. 

163.  Riesmann,  D.,  "  Cancer  of  the  Stomach,"  "  Proc.  Path.  Soc.  Phila.," 
1897,  I,  9-18. 

164.  Riess,  "  Ueber  den  Werth  der  Condurangorinde  bei  den  Symptomen- 
bild  des  Magencarcinoms,"  "  Berl.  klin.  Wochenschr.,"  1887. 

165.  Robin,  A.,  "  Traitement  medical  du  cancer  de  I'estomac,"  "  Bull, 
med.,"  13,  XI,  1897. 

166.  Robert,  "  Hematemese  terminee  par  la  mort  due  a  une  tumeur  de 
I'estomac  (sarcoma  plexiforme),"  "  Bull,  et  mem.,  Soc.  de  chir.  de  Par.,"  1898, 
N.  S.,  XXIV,  294-296. 

167.  Rokitansky,  "  Carcinoma  ventriculi,"  "  Allg.  Wien.  med.  Ztg.,"  1897, 
XIII,  93,  105,  107,  129,  142,  152. 

168.  Rokitansky,  "  Secundares  Lebercarcinom  in  Folge  von  Magenkrebs," 
"  Allg.  Wien.  med.  Ztg.,"  1898,  xliii,  105. 

169.  Rommelaere,  "  Journal  de  Med.,  de  Chir.,  et  de  Pharm.  de  Bruxelles," 
1883-86. 

170.  Rorig,  "  Primares  Cancroid  des  Magens,"  Dissert.,  Wiirzburg,  1895- 
•96. 

171.  Rosenbach,  "  Ueber  eine  eigenthiimlicheFarbstoffbildung  bei  schweren 
Darmleiden,"  "Berlin,  klin.  Wochenschr.,"  1889. 

172.  Rosenheim,  "  Ueber  atrophische  Processe  an  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  und  als  selbstandige  Erkrankung,"  Discus- 
sion, "  Berlin,  klin.  Wochenschr.,"  1888. 

173.  Rosenheim,  "  Zur  Kenntniss  des  mit  Krebs  complicirten  runden  Ma- 
gengeschwiirs,"  "  Zeitschr.  f.  klin.  Med.,"  1890. 

174.  Sabrazer  et  Cabauner,  "  Des  gangrenes  des  extremities  d'origine  arte- 
rielle  dans  le  cancer  I'estomac,"  "Arch,  gen  de  med.,"  Paris,  1898,  i,  pp. 
99-1 1 1. 

175.  Sailer,  Jos.,  and  Taylor,  A.  E.,  "The  Condition  of  the  Blood  in  the 
Cachexia  of  Carcinoma,"  "  Internat.  Med.  Magaz.,"  July,  1897. 

176.  Scheuerlen,  "  Verhandl.  d.  Ver.  f.  innere  Medicin,"  "  Deutsche  med. 
Wochenschr.,"  1887,  No.  48. 

177.  Schlesinger,  H.,  "  Klinisches  iiber  Magentumoren  nicht  carcinoma- 
toser  Natur  (Magensarkom),"  "Zeitschr.  f.  klin.  Med.,"  Bd.  xxxii,  Suppl., 
Heft  8. 

178.  Schneider,  G.,  Inaugural-Dissertation,  Berlin,  1888. 


LITERATURE   ON   CANCER   OP  THE   STOMACH.  585 

179.  Schneyer,  "  Zeitschr.  f.  klin.  Med.,"  1895. 

180.  Schoenborn,  "  Ueber  traumatische  Entstehung  eines  Magenkrebses," 
"  Aerztl.  Vereinsbl.  f.  Deutschl.,"  1897,  xxvi,  509. 

181.  Scholz,  F.,  "  Beitrage  zur  Statistik  des  Magenkrebses,"  Dissert., 
Gottigen,  1896-97. 

182.  Schiile,  "  Beitrage  zur  Diagnostik  des  Magencarcinoms,"  "Miinch. 
med.  Wochenschr.,"  1894. 

183.  Schiile,  "  Ueber  die  Fruhdiagnose  des  Carcinoma  ventriculi,"  "  Miinch. 
med.  Wochenschr.,"  No.  37,  1897. 

184.  Senator,  "  Ueber  Selbstinfection  durch  abnorme  Zersetzungsvorgange 
und  dadurch  bedingtes  dyskrasisches  Coma  (Kussmaul's  Symptomencomplex 
des  diabetischen  Comas),"  "  Zeitschr.  f.  khn.  Med.,"  1884,  vii. 

185.  Von  Sohlern,  "  Der  Einfluss  der  Ernahrung  auf  die  Entstehung  des 
Magengeschwiirs,"  "  Berl.  khn.  Wochenschr.,"  1889,  Nos.  13  and  14. 

186.  Soupalt,  M.,  "  Cancer  de  I'estomac,  stase  gastrique  sans  dilatation," 
"  Presse  med.,"  Paris,  1898,  i,  217. 

187.  Soupalt,  M.,  "  Epithelioma  du  corps  de  I'estomac,  gastrectomie  partielle  ; 
guerison,"  Soc.  anat.,  24  Dec,  1898. 

188.  Steinhaus,  "Ueber  Carcinomzelleneinschliisse,"  "  Virchow's  Archiv," 
1891,  Bd,  cxxvi, 

189.  Stempfle,  L.,  "  Ein  Fall  von  Leberabscess  im  Anschluss  an  ein  Carci- 
nomatos  entartetes  Ulcus  ventriculi,"  Dissert.,  Erlangen,  i896-'97. 

190.  Stewart,  D.  D.,  "  A  Case  of  Two  Isolated  Carcinomatous  Gastric 
Ulcers ;  Apparent  Recovery  after  Exploratory  Celiotomy ;  Death  eighteen 
months  later,  following  a  second  operation;  Hyperchlorhydria  to  the  end," 
"  Tr.  Assoc.  Amer.  Physic,"  Phila.,  1898,  xiii,  272-299. 

191.  Strauss,  "  Sarkomatosis  der  Haut  und  des  Magens,"  Dissert.,  Wiirz- 
burg,  i895-'96. 

192.  Strube,  Geo.,  "  Trichomonas  hominis  in  the  Gastric  Contents  in  Carci- 
noma of  the  Cardia,"  "  Berl.  klin.  Wochenschr.,"  Aug.  8,  1898. 

193.  Strube,  Geo.,  "  A  Case  of  Cancer  of  the  Pylorus  Presenting  Some 
Unusual  Features,"  "Lancet,"  Oct.  i,  1898,  vol.  11. 

194.  Stucky,  T.  A.,  "  Malignant  Disease  of  the  Pylorus,"  "  Internat.  Clin.," 
Phila.,  1898,  8,  3.  s.  159-163. 

195.  Szekacs,  B.,  "  Ein  Fall  von  Magenkrebs  mit  intermittierendes  Fieber," 
Budapest,  koz  korhazak  eokonyve,  1894,  rol  Budapest,  1896. 

196.  Thayer,  W.  S.,  "Johns  Hopkins  Hosp.  Bullet.,"  1893,  No.  31. 

197.  Thoma,  "  Ueber  eigenartige  parasitare  Mikroorganismen  in  den  Epi- 
thelzellen  der  Carcinome,"  "  Fortschritte  der  Medicin,"  1889,  No.  2. 

198.  Tuffier  et  Dujarier,  "  Perigastrite  gangreneuse  anterieure  suite  de  can- 
cer gastrique,"  Soc.  Anat.  de  Paris,  14.  Janv.,  1898. 

199.  Uffelmann,  "  Ueber  die  Methode  der  Untersuchung  des  Mageninhalts 
auf  freie  Salzsaure,"  "  Deutsches  Archiv  f.  klin.  Med.,"  1880,  Bd.  xvi. 

200.  UUman,  J.,  "Gastric  Carcinoma;  the  Presence  of  the  '  Faden  '  (Oppler- 
Boas)  Bacillus  as  an  Important  Factor  in  Gastric  Carcinoma,"  "  Buffalo  Med. 
Jour.,"  1-998-99,  N.  S.,  xxxviii,  18-23. 

201.  Vedel,  "  Cancer  de  I'estomac  avec  perforation  et  abouchement  dans  une 
masse  ganglionnaise  peritonite  aigue  fibrineuse,"  "  Nouv.  Montpellier  m6d.," 
28  mai,  1898. 

202.  Von  den  Velden,  "  Ueber  Vorkommen  und  Mangel  der  freien  Salzsaure 


586  MALIGNANT   TUMORS    OF    THE    STOMACH. 

im  Magensafte  bei  Gastrectasie,"  "  Deutsch.  Archiv  f.  klin.  Med.,"  1879,  ^d. 

XXIII. 

203.  Verstraete,  "Deux  cas  de  cancer  de  restomac,"  "J.  d.  sc.  med.  de 
Lille,"  1898,  I. 

204.  Vickery,  H.  F.,  "A  Report  of  Three  Cases  of  Cancer  of  the  Stomach  in 
which  Hydrochloric  Acid  was  Present,"  "  Boston  Med.  and  Surg.  Jour.,"  1897, 
cxxxvii,  132. 

205.  Vilcog  et  Lancy,  "  Cancer  de  I'estomac,  pyemic  streptococcique  second- 
aire,"  Soc.  Anat.  de  Paris,  19,  vi,  1897. 

206.  Virchow,  "  Bemerkungen  iiber  die  Carcinomzelleneinschllisse,"  "  Vir- 
chow's  Archiv,"  1892,  Bd.  cxxvii. 

207.  Virchow,  "  Krankhafte  Geschwiilste,"  i. 

208.  Volkmann,  R.,  "  Beitrage  zur  Chirurgie,"  Leipzig,  1875,  "^^^ 
"  Deutsche  Zeitschr.  f.  Chirurgie,"   1880,  Bd.  xiil. 

209.  Waldeyer,  "  Volkmann's  Sammlung  khn.  Vortrage,"  i,  No.  13. 

210.  Walker,  J.  W.,  "  A  Case  of  Pyloric  Carcinoma  and  Melancholia,  with 
Internal  Illusions,"  "  Amer.  Jour.  Insan.,"  1897,  Liii,  510-512. 

211.  Wazoldt,  "  Ueber  einen  Fall  von  Absonderung  eines  iibermassig  sauren 
Magensaftes  bei  Magencarcinom,"  "  Charite  Annalen,"  1888,  xiv. 

212.  Weber,  W.  C,  "Early  Diagnosis  of  Carcinoma  of  the  Stomach  by 
Means  of  Chemical  Analysis  of  the  Gastric  Contents,"  "  Jour.  Amer.  Med. 
Assoc,"  II,  VII,  1896. 

213.  Welch,  Wm.  H.,  "  American  System  of  Medicine,"  vol.  11,  "  Cancer  of 
the  Stomach,"  p.  53,  no  references. 

214.  West,  Charlotte  C,  "  Report  of  Two  Cases  of  Cancer  of  the  Stomach," 
"  Phila.  Polyclin.,"  1898,  vil,  107-110. 

215.  Willigk,  "Prager  Vierteljahresschrift,"  vol.  x,  2,  1853. 

216.  Winterberg,  J.,  "  Zwei  Falle  von  Magencarcinom  mit  Perforation  durch 
die  vordere  Bauchwand,"  "  Wien.  klin.  Rundschau,"  1898,  xii,  585,  607. 

217.  Witte,  W.  C.  F.,  "  Carcinoma  of  the  Stomach,  Retrogressive  Lymphatic 
Transport,  Multiple  Carcinomatous  Construction  of  the  Ileum,  and  Triple 
Simultaneous  Perforation,"  "Phila.  Med.  Jour.,"  1898,  i,  846-848. 

218.  Witzel,  "Centralbl.  f.  Chirurg.,"  1891,  No.  31. 

219.  Worthington,  N.,  "  Cancer  of  the  Stomach,"  "  Montreal  Med.  Jour.," 
1897-98,  XXVI,  601. 

220.  Wortmann,  Carl,  "  Ein  Fall  von  Carcinoma  ventriculi  im  Anschluss  an 
chronisches  Magengeschwur,"  Dissert,  Wlirzburg,  i896-'97. 

221.  Wyss,  "  Blatter  f.  Gesundheitspflege,"  Ziirich,  1872-74. 

222.  Yates,  H.  W.,  "  Cancer  of  the  Stomach,  with  Report  of  a  Case," 
"Phys.  and  Surg.,"  Detroit  and  Ann  Arbor,  1898,  xx,  147-155;  Discus- 
sion, 179. 


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589 


590     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 


CHAPTER  V. 

STOMACH  DISEASES  CAUSED  BY  INFECTIOUS 
GRANULOMATA. 

These  affections  have,  almost  exclusively,  a  purely  pathological 
significance.  Among  the  infectious  granulations  reported  as  affect- 
ing the  stomach  are  tuberculosis,  syphilis,  abdominal  typhus,  glan- 
ders, and  lymphadenoma.  We  shall  consider  gastric  tuberculosis 
and  syphilis  separately. 

Typhoid  neoplasms  and  ulcerations  of  the  stomach  are  very  rare; 
even  more  unusual  than  tuberculous  ulcerations.  The  medullary 
swelling  of  lymph-glands,  however,  as  well  as  the  ulcers  arising  there- 
from, have  been  described  as  occurring  in  the  stomach  (Orth,  "Spe- 
cielle  pathol.  Anatomic,"  Bd.  i,  S.  714). 

Concerning  the  occurrence  of  glanders  in  the  human  stomach,  only 
one  observ^ation  is  on  record — viz.,  Bollinger  (O.  Wyss),  "Rotz," 
"von  ^iemssen's  Handb.,"  Bd.  iii,  S.  482,  1876. 

Leukemic  and  aleukemic  lymphadenomata,  as  occurring  in  the 
human  stomach,  have  been  reported  several  times  ("Lmyphade- 
noma,"  Cornil  and  Ranvier,  "Manuel  de  I'Histolog.  Patholog.,"  p. 
294).  This  neoplasm  occurs  in  the  deeper  part  of  the  true  mucosa 
and  in  the  submucosa,  but  sends  prolongations  into  the  outer  layers. 
Lymphadenomata  and  glanders  may  ulcerate  on  the  inner  surface  of 
the  stomach. 

TUBERCULOSIS  OF  THE  STOMACH. 
The  gastric  mucosa  has  almost  entire  immunity  from  bacterial  in- 
fection. As  the  intestines  are  the  seat  of  frequent  infection,  when 
there  can  be  no  doubt  that  bacteria  have  entered  through  the  esopha- 
gus and  stomach,  the  immunity  of  the  last-named  organ  must  de- 
pend upon  some  peculiarity  in  its  structure  or  secretions.  Tubercle 
bacilli  are  not  affected  by  the  acid  gastric  juice,  as  has  been  proved 
by  Falk  {loc.  cit.)  and  Frank  {loc.  cit.),  who  demonstrated  that  the 
growth  of  the  bacilli  could  not  be  retarded  by  the  gastric  secretion. 
This  does  not  imply,  however,  that  these  bacilli  can  grow  in  the  gas- 
tric juice.  The  normal  stomach,  as  a  matter  of  fact,  is  not  favorable 
to  bacterial  development.  The  gastric  immunity  may  further  be 
accounted  for  by  the  scarcity  of  lymph-glands  in  the  gastric  wall.     In 


TUBERCULOSIS    OF    THE    STOMACH.  59 1 

the  intestines  lymphatic  nodules  are  abundant,  and  they  bear  some 
definite  relation  to  the  formation  of  tubercle.  The  occurrence  of 
smaller  and  larger  tuberculous  foci  in  the  stomachs  of-  adults  and 
children  proves  that  the  gastric  immunity  can  not  be  complete. 
Undoubtedly  a  number  of  conditions  must  simultaneously  cooperate 
to  bring  about  a  tuberculous  invasion.  Prominent  among  these  are : 
(i)  A  lessened  resistance  or  reduced  vitality  of  the  gastric  mucous 
membrane;  (2)  a  diminished  secretion  or  absence  of  HCl;  (3)  an 
altered  state  of  the  blood ;  (4)  the  presence  of  tubercle  bacilli. 

A  number  of  the  tuberculous  gastric  ulcerations  that  are  reported 
have  developed,  not  from  a  direct  invasion  of  the  bacilli  into  the 
mucosa,  but  from  an  invasion  into  the  serosa,  occurring  from  circum- 
scribed or  diffuse  peritonitis. 

Gastric  tuberculosis  occurs  in  two  forms — (i)  miliar}'-  tuberculosis 
of  the  wall  of  the  stomach,  a  not  uncommon  type;  (2)  tuberculous 
ulceration  of  the  stomach,  an  extremely  rare  occurrence.  Miliary 
tuberculosis  of  the  stomach  occurs  simultaneously  with  the  eruption 
of  tubercle  throughout  the  organism.  It  is  usually  found  to  exist 
with  a  miliary  tuberculosis  of  the  intestines  and  peritoneum.  These 
cases  may  strongly  resemble  severe  attacks  of  typhoid  fever.  The 
author,  while  physician-in-charge  of  Bay  View  Asylum,  Baltimore, 
observed  two  cases  of  acute  miliar}^  tuberculosis  which  were  diag- 
nosed as  typhoid  fever.  Even  the  characteristic  rose  spots  were 
present,  and  taken  for  such  by  the  author  and  other  clinicians.  This 
was  at, a  time  when  microscopical  examination  for  tubercle  bacilli 
was  not  in  vogue,  and  the  Widal  test  not  yet  discovered.  The  necrop- 
sies were  made  by  Professor  William  T.  Councilman,  revealing  acute 
miliar}^  tuberculosis. 

The  immunity  of  the  stomach  from  tuberculosis  was  shown  in  the 
experiments  of  Orth  {loc.  cit.).  By  feeding  rabbits  with  tubercle 
bacilli  he  obtained  intestinal  tuberculosis  seven  times,  and  gastric 
tuberculosis  but  once.  In  a  case  of  tuberculosis  of  the  esophagus 
reported  by  Dr.  S.  Flexner  {loc.  cit.),  although  extensive  destruction 
of  the  esophagus  existed,  and  the  pleural  cavity  had  been  opened, 
and  though  millions  of  tubercle  bacilli  must  have  been  taken  into  the 
stomach,  this  observer  assured  us  that  no  gastric  tuberculosis  was 
detected. 

Clinically,  gastric  tuberculosis  is  without  much  significance.  It  is, 
as  a  rule,  not  diagnosticated.  Tuberculous  ulcerations  are  found 
most  frequently  in  the  pyloric  part,  and  Orth  describes  isolated 
39 


592     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

miliary  tubercles  occurring  in  the  vicinity  of  ulcerations.  In  rare 
cases  tuberculous  ulcerations  have  produced  fatal  symptoms  by  dis- 
integrating and  eroding  a  gastric  artery,  or  by  perforating  the  gastric 
wall.  The  demonstration  of  the  tubercle  bacillus  in  a  gastric  ulcer 
was  first  made  by  Coats  {loc.  cit.).  Matthieu  and  Remond  {loc.  cit.), 
Musser  {loc.  cit.),  and  Serafini  {loc.  cit.),  in  their  cases,  also  succeeded 
in  proving  the  presence  of  tubercle  bacilli.  Kuhl  examined  for  the 
tubercle  bacillus  in  four  cases  from  the  Pathological  Museum  of  the 
University  of  Kiel,  but  could  demonstrate  it  positively  in  only  two 
of  these,  which  were  recent  cases.  The  other  two  were  older  speci- 
mens, having  been  in  the  museum  a  long  time.  A  large  number  of 
the  reported  cases  of  tubercular  ulcers  are  doubtful,  either  because 
no  microscopic  examination  was  made  at  all,  or  the  authors  failed  to 
stain  for  the  bacillus.  Such  cases  are  those  of  Paulicky  {loc.  cit.), 
Hebb  {loc.  cit.),  Chvostek  {loc.  cit.,  four  cases),  Lange  {loc.  cit.), 
Barlow  {loc.  cit.),  Ouenu  {loc.  cit.),  and  Bignon.  The  earliest  re- 
ported case  of  tubercular  ulcer  is  Litten's  {loc.  cit.),  which  showed 
an  isolated  ulcer  on  the  anterior  gastric  wall,  with  typical  giant 
cells  and  caseating  tubercles.  Letorey  {loc.  cit.)  recently  reported 
a  case,  and  gave  an  analysis  of  21  cases.  In  1887  Marfan  reviewed 
the  subject,  and  collected  14  authenticated  cases.  The  disease  is 
most  frequently  found  in  males.  In  19  cases  collected  by  I^etorey, 
in  which  the  sex  was  stated,  it  occurred  16  times  in  males  and  3 
times  in  females.  The  ulcers  are  usually  single.  In  a  case  from 
Professor  Osier's  clinic,  however,  at  the  Johns  Hopkins  Hospital 
(parts  of  this  stomach  were  presented  to  the  author  for  examination 
through  the  kindness  of  Dr.  S.  Flexner,  who  performed  the  autopsy), 
there  were  numerous  ulcers  of  various  sizes.  In  this  case  the  intes- 
tines were  also  the  seat  of  numerous  ulcerations  penetrating  to  the 
muscular  coat.  The  stomach  showed  118  to  120  areas  of  loss  of  sub- 
stance over  the  entire  organ,  but  most  thickly  on  the  anterior  surface 
near  the  greater  curvature.  Hermann  Diirck  {loc.  cit.)  observed  four 
cases  of  undoubted  tuberculous  ulcer  in  900  autopsies  at  Munich. 
Frerichs  and  Litten  have  reported  cases  in  which  the  tuberculous 
ulceration  was  limited  to  the  stomach,  the  intestines  being  intact. 
The  sizes  of  the  ulcers  vary  from  a  pin's  head  to  five  centimeters  in 
diameter.  Musser  {loc.  cit.)  has  reported  a  case  of  a  tuberculous 
ulcer  1x3  inches  in  extent;  and  in  one  of  the  cases  of  Diirck  {loc. 
cit.),  occurring  in  a  child  ten  years  old,  there  existed  an  ulcer  exceed- 
ing in  size  that  of  a  German  five-mark  piece  (somewhat  larger  than  a 
silver  dollar).     Secondar}^  tuberculous  changes  may  extend  to  the 


TUBERCULOSIS   OF   THE   STOMACH.  -  593 

stomach  through  perforation  resulting  from  caseating  neighboring 
lymph-glands.  This  is  generally  rapidly  followed  by  purulent  pro- 
cesses in  the  glands.  When  the  peritoneum  of  the  stomach  becomes 
involved  in  a  general  peritoneal  tuberculosis,  the  posterior  wall  of  the 
organ,  which  is  probably  the  most  protected,  is  either  entirely  free, 
or,  at  any  rate,  is  much  less  affected  than  the  anterior  wall. 

Habershon  {loc.  cit.)  assumes  that  infection  of  the  gastric  mucosa 
occurs  by  way  of  the  vascular  channels.  He  does  not  believe  in  a 
direct  infection  of  the  mucosa  because  of  the  acidity  of  the  gastric 
juice.  Klebs  ("Tuberculose,"  published  by  Leopold  Voss,  1894,  p. 
80)  assumes  that  tuberculous  new  formations  occur  on  the  basis  of 
preexisting  gastric  ulcers.  A  critical  review  of  the  literature  is  given 
in  an  interesting  report  of  multiple  tuberculous  ulcers  of  the  stomach 
(three  cases,  by  Alice  Hamilton,  M.D.,  "Johns  Hopkins  Hospital 
Bulletin,"  April,  1897). 

The  b-bliography,  though  extensive,  is  not  quite  complete,  and  we 
have,  in  the  following,  added  cases  which  have  come  to  our  notice. 
In  these  three  cases  tubercle  bacilli  were  demonstrated  by  the  Ziehl- 
Neelsen  method  of  staining.  Dr.  Hamilton  inclines  to  the  opinion  of 
Klebs,  that  gastric  erosions,  or  previously  existing  losses  of  substance, 
constitute  the  portals  of  entry  for  the  tubercle  bacillus.  The  facts  in 
the  second  case  indicate  that  many  small  erosions  of  hemorrhagic 
origin  preexisted  in  the  stomach,  some  of  which  became  invaded  with 
tubercle  bacilli  swallowed  with  the  sputum.  Perforation  not  infre- 
quently occurs.  It  was  present  six  times  in  the  fourteen  cases  re- 
ported by  Marfan — three  times  through  a  tuberculous  gland.  In 
eight  of  Letorey's  cases  the  presence  of  a  gastric  tuberculosis  was 
suspected  during  life  and  confirmed  at  the  necropsy.  Death  by  per- 
foration peritonitis  resulted  in  a  case  reported  by  Paulicky  {loc.  cit.). 
Most  frequently  death  results  from  advanced  tuberculosis  in  other 
organs.  In  three  of  the  cases  death  was  caused  by  severe  hemorrhage 
following  an  erosion  of  a  blood-vessel  through  the  ulcerative  process. 
In  the  critical  consideration  of  the  subject  by  Dr.  Hamilton  {loc.  cii.) 
it  was  found  that  the  authentic  literature  contained  fifteen  undoubted 
cases,  and  nine  more,  which  were  probable,  but  not  proved.  While 
there  is  a  disposition  for  development  of  tuberculosis  in  the  intestine, 
there  are  numerous  cases  reported  whereulcers  existed  in  the  stomach, 
the  intestines  being  wholly  exempt.  The  deepest  ulcers,  when  found 
multiple  in  the  stomach,  do  not  extend  beyond  the  muscularis  mu- 
cosae, and  the  infiltration  of  the  mucous  membrane  extends  little 


594    STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GR/VNULOMATA. 

further  than  the  actual  ulceration.  These  facts  are  very  evident  in 
the  sections  kindly  presented  to  the  author  by  Dr.  S.  Flexner,  and 
which  were  taken  from  the  cases  reported  by  Dr.  Hamilton.  Super- 
ficial small  ulcerations  still  showed  vestiges  of  glands,  but  without  any 
recognizable  distinction  between  oxyntic  and  chief  cells.  Epithelioid 
and  lymphoid  cells  were  profusely  scattered  throughout  the  remnants 
of  mucous  membrane.  The  free  surfaces  of  the  ulcers  were  in  a  state 
of  necrosis,  covered  at  times  by  a  homogeneous,  finely  granular  mat- 
ter. The  deeper  layers  were  in  a  state  of  comparative  preservation. 
Tubercle  bacilli  were  present  in  small  numbers,  both  on  the  free  sur- 
face of  the  ulcers  and  among  the  remnants  of  the  glands.  LetuUe 
(Anatom.  Societe  Paris,  1893;  also  abstracted  in  "Centralbl.  f.  all- 
gem.  Pathologic,"  Bd.  iv,  1893,  S.  760)  in  108  autopsies  on  un- 
doubted cases  of  pulmonary^  tuberculosis,  found  but  one  case  of  tuber- 
culosis of  the  stomach.  The  organ  presented  ten  submucous  nodules 
as  large  as  peas,  containing  giant  cells  and  a  few  tubercle  bacilli. 

Diagnosis. — The  diagnosis  of  the  possible  tuberculous  nature  of  a 
gastric  ulcer  during  life  is  certainly  very  problematical.  Tubercle 
bacilli  that  may  be  found  in  the  gastric  contents  do  not  serve  to  throw 
light  on  the  subject.  They  may  have  been  swallowed,  or  they  may 
have  been  contained  in  the  food.  The  only  possibility  would  be  to 
use  a  weak  hypodermic  injection  of  tuberculin  (one  milligram),  and  if 
a  temperature  reaction  follows  when  all  signs  of  tuberculosis  in  the 
lungs,  larynx,  and  other  organs  are  absent,  then  the  diagnosis  of  a 
local  tubercular  ulcer  in  the  stomach  would  be  justifiable.  J.  Pet- 
ruschky  ("Verhandlungen  d.  XVI.  Congress,  f.  innere  Medicin," 
April,  1899,  S.  366)  reports  two  cases  with  the  typical  clinical  history 
of  gastric  ulcer  that  did  not  improve  after  the  most  approved  treat- 
ment for  this  disease.  An  injection  of  one  milligram  of  tuberculin 
was  followed  in  five  days  by  five  milligrams,  and  in  six  days  by  ten 
milligrams.  After  the  third  injection  a  violent  reaction  set  in,  par- 
ticularly an  intense  local  reaction  of  the  stomach,  expressing  itself 
in  vomiting  (without  blood)  and  gastralgic  pains.  There  were  no 
reactions  on  the  part  of  the  lungs  or  other  organs.  After  every  injec- 
tion an  increased  sensitiveness  of  the  gastric  region  was  evident. 
The  diet  consisted  mainly  of  milk,  and  no  internal  medication  was 
given.  The  general  condition  and  strength  of  the  patient  improved 
visibly.  Toward  the  end  of  the  treatment  the  patient  received  injec- 
tions containing  100  milligrams.  Recovery  was  complete  after  three 
months.     The  first  case  continued  well  without  a  relapse  for  five 


LITERATURE   ON   GASTRIC   TUBERCULOSIS.  595 

years.  The  cure  of  the  second  case  was  not  complete  at  date  of  re- 
port. This  author  states  that  the  test-meals  from  these  cases,  a  half- 
hour  after  an  Ewald  test-breakfast,  showed  a  distinct  reaction  for  free 
HCl.  This  evidence  might  be  useful  in  the  rare  cases  where  tuber- 
cular ulcer  might  be  confounded  w4th  carcinoma. 


LITERATURE  ON  GASTRIC  TUBERCULOSIS. 

1.  Anger,  in  Marfan's  "Thesis,"'  Paris,  1887. 

2.  Barbacci,  "  Lo  Sperimentale,"  May,  1890. 

3.  Barlow,  Path.  Soc,  London,  1887. 

4.  Beadles,  "  British  Med.  Jour.,"  1892,  11. 

5.  Bellrose,  N.  W.,  "  Gastric  Ulcer,  Probably  Tubercular,  Report  of  a  Case," 
"  Colorado  Med.  Jour,,"  1897,  iir. 

6.  Birch-Hirschfeld,  "  Lehrbuch  d.  path.  Anat.,"  Bd.  il,  S.  642. 

7.  Bias,  "  Ueber  tuberculose  Geschwiire  des  Magens,"  Dissert.,  Miinchen, 
i895-'96, 

8.  Blumer,  G.,  "  Tuberculosis  of  the  Stomach,  with  a  Report  of  a  Case  of 
Multiple  Tuberculous  Ulcers  of  that  Organ,"  "  Albany  Med.  Ann.,"  1898,  xix. 

9.  Brechemin,  "  Progres  Medical,"  1879. 

10.  Cazin,  in  Fernet's  article,  "  Bull,  et  Mem.  d.  1'  Soc.  Med.  des  Hop.," 
1880,  tome  XVII. 

11.  Chvostek,  "  Wien.  med.  Blatter,"  1882,  v. 

12.  Coats,  "Glasgow  Med.  Jour.,"  1886. 

13.  Cordua,  "  Arbeiten  aus  dem  patholog.  Institut  in  Gottingen,"  Berlin, 
1893. 

14.  Duguet,  in  Spillman's  "These,"  Paris,  1878. 

15.  Diirck,  Hermann,  "  Ergeb.  d.  allgem.  Path."  (Four  Cases  of  Tubercu- 
lous Ulcer  in  Nine  Hundred  Autopsies). 

16.' Eppinger,  "  Prager  med.  Wochenschr.,"  1881. 

17.  Falk,  "  Virchow's  Archiv,"  Bd.  xciil,  S.  177. 

18.  Flexner,  S.,  "  Tuberculosis  of  Esophagus,"  Bull.  Johns  Hop.  Hosp.," 
No.  28,  1893. 

19.  Frank,  "  Deutsche  med.  Wochenschr.,"  1884,  No.  20. 

20.  Habershon,  S.  H.,  "Trans.  Path.  Soc,"  London,  vol.  XLV,  p.  73. 

21.  Hamilton,  Alice,  "Johns  Hopkins  Hospit.  Bulletin,"  April,  1897. 

22.  Hattute,  "  Gaz.  des  Hop.,"  1874. 

23.  Hebb,  G.,  "Westminster  Hosp.  Reports,"  1888,  in. 

24.  Kanzow,    "  Ein    Beitrag   zur    Casuistik   der    tuberculosen    Magenge- 
schwure,"  Dissert.,  Miinchen,  1893-96. 

25.  Kuhl,  "Thesis,"  Kiel,  1889. 

26.  Labadie-Lagrave,  "Bull.  Soc.  Anat.,"  1870. 

27.  Lange,  "  Memorabilien,"  Heilbronn,  1871,  xvi. 

28.  Lava,  "Gazz.  Med.  di  Forino,"  1893. 

29.  Letorey,  "These,"  Paris,  1895. 

30.  Litten,  "Virchow's  Archiv,"  1876. 

31.  Lorey,  "  Bull.  d.  I'  Soc.  Anat.,"  1874. 

32.  "  Lubarsch  und  Ostertag,"  vol.  11,  p.  336. 


596     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRAXULOMATA. 

33.  Marfan,  "These,"  Paris,  1887. 

34.  Mathieu  and  Remond,  in  Letorey's  "Tliesis,"  Paris,  1875. 

35.  Mathieu,  "Bull.  d.  1'  Soc.  Anat.,"  1881. 

36.  MuUer,  K.,  "  Ueber  Dyspepsia  prsetuberculosa,"  "  Ungar.  med.  Presse," 
Budapest,  1898,  iii. 

37.  Musser,  "  Phila.  Hosp.  Reports,"  1890,  i. 

38.  Oppolzer,  in  Marfan's  "These,"  Paris,  1887. 

39.  Orth,  "  Exper.  Magengeschw.,"  "  Virchow's  Archiv,"  Bd.  lxxvi. 

40.  Packard,  F.  A.,  "  Tuberculous  Ulcer  of  the  Stomach,"  "  Tr.  Path.  Soc," 
Phila.,  1898,  XVIII. 

41.  Paulicky,  "Berlin,  klin.  Wochenschr.,"  1867. 
•42.  Pozzi,  "Bull.  Soc.  Anat.,"  1868. 

43.  Prezewoski,    "Gastritis    Tuberculosa"     (five    cases),     "  Centralbl.     f. 
allgem.  Path.  u.  path.  Anat.,"  Bd.  vi,  S.  270. 

44.  Quenu,  in  Marfan's  "Thesis,"  Paris,  1887. 

45.  Serafini,  "Annal.  clin.  del.  Osp.  di  Napoli,"  1888. 

46.  Talamon,  "  Progres  I\Ied.,"  1879. 

47.  Weinberg,  "Ulceration  Tuberculeuse  de  I'estomac," '"  Soc.  Anat.  de 
Paris,"  5,  VI,  1897. 

48.  Wilms,  M.,  "  Miliar  tuberculose  des  ]\Iagens,"  "  Centralbl.  f.  allg.  Path. 
u.  path.  Anat.,"  Jena,  1897,  viii. 

49.  Petruschky,  "  Verhandlung.  d.  XVI.  Congress,  fiir  innere  Medicin,"  Wies- 
baden, April,  1899. 


SYPHILIS  OF  THE  STOMACH. 

Pathological  changes  caused  by  S3-philis  occur  in  the  stomach  in 
two  main  forms — (i)  the  syphilitic  ulcer  and  (2)  the  syphilitic  neo- 
plasms. In  addition  to  these  the  author  recognizes  a  third  form — 
(3)  the  diffuse  syphilitic  gastritis  (chronic  form).  WTiile  the  first 
two  forms  are  due  to  direct  syphilitic  disease,  the  third  form  may  be 
due  to  indirect  syphilis — for  instance,  to  the  formation  of  countless 
syphilitic  gummata,  forming  nodules  in  the  mucosa  and  submucosa 
barely  visible  to  the  naked  eye.  This  third  form,  in  the  majority  of 
cases,  is  probably  due  to  what  Chiari  terms  indirect  syphilis — that  is, 
due  to  circulatory  disturbances,  passive  congestions,  hemorrhages, 
etc.,  produced  by  syphilitic  disease  of  other  organs,  especially  of  the 
liver. 

Gastric  disturbances  are  observed  in  individuals  affected  with 
syphilis,  even  at  an  early  prodromal  stage  of  cutaneous  eruptions. 
These  patients  may  develop  all  the  symptoms  of  acute  gastritis, 
with  a  feeling  of  pressure,  fullness  in  the  stomach,  loss  of  appetite, 
nausea,  etc.  The  sj'mptoms  of  acute  or  subacute  gastritis  may  be 
accompanied  by  gastralgia,  coated  tongue,  headache,  and  actual 
vomiting.     These  symptoms  can  not  be  pronounced  as  syphilitic, 


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SYPHIIvIS    OF   THE    STOMACH.  597 

because  other  etiological  factors  can  not  be  excluded;  one  is  there- 
fore disposed  to  assign  the  gastric  S3^mptoms  to  better  known  causes. 
Allen  A.  Jones  has  reported  two  cases  of  gastralgia,  which  were  un- 
doubtedly caused  by  syphilis  ("Phila.  Med.  Jour.,"  vol.  iii,  p.  958). 
Acute  diseases  of  the  neighboring  organs  (liver,  pancreas,  and  spleen) 
are  not  so  rare  in  syphilis  as  was  assumed  not  long  ago.  Jullien  (loc. 
cit.)  describes  attacks  of  vomiting,  colic,  and  diarrhea  in  the  course  of 
recent  syphilis;  and,  according  to  Fournier  {loc.  cit.),  bulimia  is,  in 
rare  cases,  a  symptom  in  severe  forms  of  lues.  This  condition  is 
observed  more  frequently  in  women  than  in  men,  and  occurs  between 
the  third  and  sixth  month  of  the  disease.  According  to  this  author, 
it  is  sometimes  associated  with  polydipsia.  In  a  consideration  of  the 
previous  gastric  diseases  we  have  seen  that  the  nerves  react  in  a  very 
sensitive  manner  to  certain  anomalous  states  of  the  blood — anemias, 
etc.  In  lues  we  have  characteristic  reduction  of  the  erythrocytes 
and  of  the  percentage  of  hemoglobin.  We  might  trace  the  symp- 
toms described  to  these  blood  conditions  in  preference  to  ascribing 
them  to  disease  of  the  gastric  mucosa. 

Chronic  Gastritis  Due  to  Syphilis. — This  is  a  rather  frequent 
and  important  syphilitic  affection,  and  is  one  of  the  main  causes  of 
the  poor  state  of  nutrition  in  luetics.  It  is,  as  a  rule,  associated  with 
characteristic  syphilitic  disease  in  other  digestive  organs  (spleen, 
pancreas,  and  liver).  Histologically,  it  may  be  found  to  be  a  simple 
chronic  gastritis,  or  else  combined  with  gummata  or  gummatous 
ulcers,  and  is  then  a  phenomenon  of  the  later  stages.  Syphilitic 
chronic  gastritis,  in  the  absence  of  gummata  or  gummatous  ulcers, 
does  not  differ  pathologically  from  ordinary  chronic  gastritis,  except 
in  the  greater  frequency  of  small  round-cell  accumulation,  especially 
in  the  submucosa,  sometimes  appearing  like  miliary  gummata.  The 
cases  that  are  described  by  Virchow  {loc.  cit.)  were  due  to  chronic 
passive  hyperemia  caused  by  circulatory  disturbances,  and,  in  our 
opinion,  present  nothing  characteristic  of  syphilitic  gastritis.  Chronic 
syphilitic  gastritis  may  develop  from  repeated  attacks  of  the  acute 
form,  just  as  with  non-specific  chronic  gastritis.  Relapses  are  not 
necessarily  due  to  syphilis. 

If  characteristic  syphilitic  lesions  exist  in  the  liver,  kidneys,  spleen, 
pancreas,  or  intestines,  the  chronic  gastritis  should,  in  my  opinion,  be 
attributed  to  syphiHs.  In  tertiary  syphilis  the  remarkable  malnutri- 
tion is  due  to  a  chronic  luetic  gastritis.     The  clinical  phenomena  of 


598     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

luetic  gastritis  are  not  different  from  the  non-specific  inflammations 
of  the  stomach. 

Diagnosis. — It  is  conceded  by  gastro-enterologists  that  iodids  and 
salts  of  mercury  have  a  deleterious  effect  upon  the  gastric  functions  in 
normal  individuals.  If,  therefore,  the  symptoms  of  gastritis  develop 
in  a  confirmed  luetic,  and  improve  upon  the  administration  of  iodid 
of  mercury,  getting  worse  when  the  mercur\^  is  discontinued  and  im- 
proving again  when  the  drug  is  resumed,  the  diagnosis  of  chronic 
syphilitic  gastritis  is  logical. 

We  have  observed  symptoms  of  acute  gastritis  in  a  child  eleven 
years  old,  daughter  of  a  man  who  had  contracted  syphilis  while  he 
was  a  soldier  in  the  German  army  in  the  Franco-Prussian  war,  1870- 
'71.  The  father  of  this  child  has  had  maniacal  attacks,  in  which  he 
had  to  be  restrained.  About  once  a  month  he  has  typical  epileptic 
convulsions,  which  may  last,  with  short  intervals,  for  ten  to  twelve 
hours,  with  foaming  at  the  mouth,  involuntary  evacuations,  etc.  He 
admits  the  original  infection,  and  gives  a  correct  history  of  primary 
and  secondary  syphilis.  The  child  recently  developed  a  huge  gumma 
of  the  lower  jaw,  which  assumed  the  dimensions  of  a  goiter.  The 
gastric  symptoms  were  incessant  vomiting  and  gastralgia.  By 
treatment  with  mercurial  inunctions  the  stomach  symptoms  disap- 
peared in  the  course  of  two  weeks;  the  child  was  apparently  cured 
after  six  weeks  of  this  treatment.  The  efficac}''  of  this  form  of  treat- 
ment was  all  the  more  fortunate  since  the  child  could  retain  nothing 
on  its  stomach  and  medication  by  the  mouth  would  have  been  futile. 
Two  years  ago  the  author  treated  another  child  of  this  man  (his  wife, 
by  the  way,  has  had  four  miscarriages),  for  gastralgia,  nausea,  eructa- 
tions, and  vomiting,  by  mercurial  inunctions  and  a  saturated  solution 
of  iodid  of  potassium.  The  child  took  as  much  as  forty  drops  of  the 
saturated  solution  of  KI  three  times  a  day,  with  evidences  of  distinct 
improvement,  the  symptoms  subsiding  entirely  at  the  end  of  three 
weeks.  In  both  of  these  children  the  vomit  during  the  attacks  con- 
tained no  free  HCl,  but  enormous  quantities  of  mucus,  and  curdled 
milk  but  weakly.  Both  HCl  and  ferment  secretion  were  restored  by 
the  treatment.  Tullio  (loc.  cit.)  reports  improvement  and  cure  of 
severe  chronic  gastritis  b}^  iodid  of  mercury  given  internally.  The 
patient  became  worse  when  the  mercury  was  discontinued.  Non- 
syphilitics  were  made  dyspeptic  by  taking  iodid  of  mercur3\  The 
following  conclusions  appear  to  us  to  be  logical.  When  digestive 
disturbances  resembling  those  of  gastritis  occur  in  a  syphilitic,  and 


HISTOLOGY    OF    SYPHILITIC    GASTRITIS.  599 

other  etiological  factors  can  be  excluded,  the  diagnosis  of  syphilitic 
gastritis  is  correct  if  the  phenomena  disappear  under  antisyphilitic 
treatment.  The  diagnosis,  then,  depends  upon  the  evidence  of  unde- 
niable syphilis  as  a  cause,  and  the  disappearance  of  gastric  symptoms 
under  antisyphilitic  treatment.  Professor  S.  Flexner  (pathologist  to 
the  Johns  Hopkins  Hospital)  presented  us  with  the  stomach  of  a 
syphilitic  negro  who  had  gummata  in  the  following  places:  (i) 
Frontal  bone,  extending  into  the  meninges  and  frontal  cerebral  con- 
volutions; (2)  one  in  the  liver;  (3)  one  in  the  spleen;  (4)  three  in 
mesenteric  glands;  (5)  one  in  the  testes  and  epididymis.  The  au- 
thor was  present  at  the  autopsy,  which  was  made  by  Dr.  Flexner. 
After  hardening  in  formol,  the  sections  were  stained  in  orange-G. 
and  hematoxylin.  All  the  sections,  no  matter  from  what  portion  of 
the  stomach  they  were  taken,  showed  an  intense  diffuse  gastritis. 
At  first  we  failed  to  find  characteristic  evidence  of  lues.  The  surface 
of  the  mucosa  was  covered  with  finely  granular  elevations,  quite 
evident  to  the  naked  eye.  The  surface  cylindrical  epithelium  w^as 
lost  entirely.  There  was  a  very  characterictic  endarteritis  and  thick- 
ening of  the  vessel  walls,  producing  occlusion  of  the  lumen  (endarteri- 
tis obliterans).  Throughout  the  mucosa  and  submucosa  were  count- 
less miliary  nodules,  about  the  size  of  a  pin's  head,  composed  of  ap- 
parently densely  packed  collections  of  small  round  cells.  Some  of 
these  nodules  exhibited  themselves  in  the  submucosa,  but  in  that 
situation  they  were  rare.  The  majority  of  them  rested  upon  the 
muscularis  mucosae,  and  thence  extended  upward  into  the  glandular 
layer,  pushing  apart,  compressing,  and  distorting  what  was  left  of  the 
gland  ducts.  Some  of  the  small  round-cell  infiltrations  resembled 
normal  lymph-glands  of  the  stomach.  The  majority  of  them  were, 
however,  larger  than  the  gastric  lymph-glands,  extending  from  the 
submucosa  to  the  surface  of  the  mucous  membrane.  (See  illustra- 
tion, plate  X.)  One  of  our  artists  (Mr.  Touis  Schmidt)  has  given  a 
graphic  illustration  of  the  condition  present.  In  many  places  collec- 
tions of  round  cells  had  forced  asunder  the  fibers  of  the  muscularis 
mucosae,  splitting  apart  this  layer,  which  usually  runs  along  in  one 
stratum.  In  some  places  the  muscularis  mucosae  was  seemingly  torn 
apart  and  forced  either  downward  into  the  submucosa,  or  upward 
into  the  mucosa,  in  large  bundles,  by  infiltrating  masses  of  round  cells 
and  also  by  proliferation  of  the  muscle-fibers.  The  longitudinal 
layer  of  muscle-fibers  was  similarly  split  up  by  enormous  -collections 
of  round-cell  infiltration.     The  fibers  of  the  muscularis  mucosae  nor- 


6oO     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

mally  ascend  into  the  glandular  layer  and  surround  the  gland  tubules. 
We  have,  however,  never  seen  these  muscle-fibers  ascending  in  such 
masses  as  in  these  specimens.  In  places  the  entire  glandular  layer 
was  replaced  by  a  mass  of  small  round  cells.  The  left  side  of  the 
illustration  represents  one  of  the  miliary  nodules,  showing  a  gradual 
breaking  down  or  softening  at  the  side.  Although  at  first  inclined 
to  consider  this  whole  process  due  to  indirect  syphilis,  caused  by 
passive  congestion  due  to  the  luetic  hepatitis  (a  large  gumma  being 
present  in  the  liver),  the  finding  of  nodules  as  large  as  a  pin's  head 
(which  showed  signs  of  softening)  suggests  that  we  may  possibly  be 
dealing  with  minute  miliary  gummata.  Chiari  {loc.  cit.)  reported 
243  autopsies  of  undoubted  syphilitics:  145  were  hereditar^^  and  98 
acquired  syphilis.  His  conclusions  are  the  following:  (i)  Patho- 
logical changes  caused  by  syphilis  really  occur  in  the  stomach;  (2) 
they  may  be  direct  syphilitic  changes,  or  owe  their  origin  indirectly 
to  syphilis;  (3)  the  direct  syphilis  of  the  stomach  is  a  great  rarity, 
and  is  either  a  gummatous  process  or  a  simple  inflammatory  infiltra- 
tion ;  the  latter  occurs  only  in  the  hereditary  form ;  (4)  the  indirect 
syphilitic  affections  of  the  stomach  are  due  to  circulatory  disturb- 
ances caused  by  syphilis  of  the  other  organs,  especially  of  the  liver,  or 
else  they  are  due  to  gastric  hemorrhages  occurring  interstitially  as 
phenomena  of  a  syphilitic  hemorrhagic  diathesis;  (5)  gummatous 
processes  in  the  stomach  are  characterized  by  presence  of  gummatous 
tissues ;  they  are  first  developed  in  the  submucosa,  and  enter  the 
other  layers  from  there;  (6)  syphilitic  gastric  ulcers  may  be  caused 
by  disintegration  and  autodigestion.  The  cicatrices  in  the  stomach 
demonstrated  by  Cornil  {loc.  cit.)  and  Weichselbaum  {loc.  cit.)  could 
be  attributed  to  syphilis  only  if  gummatous  tissue  or  other  non-ulcer- 
ating gummata  were  present. 

Only  in  three  cases  could  Chiari  designate  the  changes  as  direct 
syphilis — one  gumma  in  a  case  of  hereditary  syphilis,  one  gumma  in  a 
case  of  acquired  syphilis,  and  one  in  diffuse  inflammatory  infiltration 
of  the  mucosa  and  submucosa  in  hereditary  syphilis.  His  percentage 
of  gastric  syphilis  was  1.2  per  cent,  of  the  total  material  of  243  sec- 
tions :  1.3  per  cent,  in  hereditary'  syphilis,  and  1.2  per  cent,  of  acquired 
syphilis. 

Syphilitic  Ulcers  of  the  Stomach. — In  a  study  of  the  subjoined 
literature  authentic  cases  of  syphilitic  gastric  ulcers  are  not  so  scarce 
as  one  might  presume.  Galliard  {loc.  cit.)  and  Cruveilhier  {loc.  cit.) 
were  disposed  to  believe  in  a  causative  relation  between  simple  gastric 


GASTRIC    ULCER   RESULTING    FROM    SYPHILIS.  6oi 

ulcer  and  syphilis.  Among  one  hundred  cases  of  gastric  ulcer,  Engel 
could  trace  a  syphilitic  history  in  ten  per  cent.  T.  I^ang  {loc.  cit.) 
stated  that  twenty  per  cent,  of  gastric  ulcers  occur  in  syphilis.  Ewald 
expresses  himself  with  doubt  on  this  subject :  "It  must  remain  ques- 
tionable," he  says,  "in  two  diseases  as  common  as  those  under  dis- 
cussion, whether  we  are  dealing  with  cause  and  effect,  or  with  acci- 
dental coincidents."  Frerichs,  Drozda,  Murchison,  and  Chvostek 
found  scars  in  the  stomach,  coincidently  with  general  syphilis.  Gas- 
tric ulcers  may  occur  in  syphilitics  from  necrosis  of  the  mucosa,  due 
to  specific  endarteritis,  or  to  disintegration  and  breaking  down  of  a 
gumma.  In  1838  Andral  {loc.  cit.)  concluded  that  a  gastric  ulcer  in 
his  clinic  was  due  to  syphilis  because  it  was  cured  by  mercurial  treat- 
ment. Rosanow  {loc.  cit.)  described  a  case  in  a  soldier  who  had  suf- 
fered from  gastric  ulcer  for  eight  years  and  had  been  treated  by  him 
for  two  months  by  typical  ulcer  treatment.  The  cardialgia,  however, 
continued,  and  was  associated  with  pains  in  the  lower  extremities. 
The  patient  showed  no  signs  of  lues.  He  was  cured  in  forty-seven 
days  by  treatment  by  inunctions  and  iodid  of  potassium.  It  is  nec- 
essary to  distinguish  between  typical  simple  round  ulcers  occurring 
in  syphilitics,  and  gummatous  ulcerations,  with  gastritis.  According 
to  Wagner  {loc.  ct/.)  and  Klebs  {loc.  cit.),  all  ulcers  found  in  the  stomachs 
of  syphilitics  have  arisen  from  gummata,  but  Galliard  {loc.  cit.),  Lang 
{loc.  cit.),  and  Mauriac  {loc.  cit.)  differ  from  this  opinion,  and  hold 
that  the  syphilitic  gastric  ulcers  do  not  necessarily  arise  from  gum- 
mata. 

T.  Lang's  {loc.  cit.)  statistics  indicate  that  twenty  per  cent,  of 
gastric  ulcers  occur  in  luetic  subjects,  and  Neumann  {loc.  cit.)  asserts 
that  syphilis  is  more  often  the  cause  of  gastric  ulcer  than  has  been 
hitherto  believed ;  furthermore,  that  gastric  ulcers  occurring  in  syphi- 
lis do  not  develop  from  gummata,  but  have  the  same  manifold  etiology 
as  the  non-specific  ulcer.  They  may  develop  from  erosions,  which  are 
very  frequent  in  syphilitics;  from  endarteritis;  from  diminution  in 
the  amount  of  hemoglobin;  and  from  reduction  of  the  alkalinity  of 
the  blood,  increase  and  disintegration  of  the  leukocytes.  These 
states  are  characteristic  of  lues,  and  are  accepted  as  etiological  factors 
of  round  ulcers  also.  To  these  might  be  added  hyperacidity  and 
bacterial  infection  causing  necrosis.  In  a  case  of  Fauvel's  {loc.  cit.) 
the  stomach  showed  chronic  gastritis  and  several  ulcers.  In  a  case  of 
Capozzi's  {loc.  cit.)  numerous  ulcerations  of  the  mucosa  extended 
from  the  cardia  along  the  greater  curvature  to  the  pylorus.     In  a  case 


6o2     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

of  Oser's  the  patient  was  affected  with  a  syphilitic  papulous  eruption 
and  psoriasis  palmaris,  the  gastric  mucosa  was  injected  and  per- 
meated b}-  numerous  hemorrhagic  erosions. 

The  symptoms,  course,  and  termination  of  syphilitic  gastric  ulcers  are 
not  dift'erent  from  the  non-syphilitic.  In  a  case  of  Rosanow's  {loc.  cit.) 
the  gastralgia  occurred  only  at  night,  and  from  this  the  author  diag- 
nosticated the  probable  syphilitic  nature  of  the  ulcer.  Bartumeus 
{loc.  cit.)  speaks  of  nightly  vomiting  occurring  with  syphilitic  ulcer. 

Diagnosis. — "WTien  other  etiological  factors — such  as  tuberculosis, 
alcoholism,  chlorosis,  and  the  manifold  causes  which  have  been  enu- 
merated in  the  article  on  ulcer — can  be  excluded,  and  undoubted 
svphilis  can  be  established,  the  diagnosis  of  the  syphilitic  origin  of 
gastric  ulcer  might  be  made,  although  not  with  certainty.  The  diag- 
noses of  Andral  {loc.  cit.),  Ha^^em  {loc.  cit.),  and  Mark  {loc.  cit.)  were 
based  upon  the  curatiA'e  effect  of  antisyphilitic  treatment. 

Prognosis. — Wagner  {loc.  cit.),  Lanceraux,  and  others,  report  cures 
of  syphilitic  ulcers  by  iodid  of  potassium.  The  conditions  after  the 
reported  cures  were  similar  to  those  existing  after  the  cures  of  non- 
specific ulcers.  Stenosis  of  the  pylorus  and  chronic  gastritis  follow- 
ing svphilitic  ulcers  have  been  observed  b}^  Comil,  Capozzi,  Wagner, 
Fauvel,  and  Klebs.  The  direct  cause  of  death  in  autopsies  of  cases 
of  svphilitic  gastric  ulcers  hitherto  reported  was  plainly  attributable  to 
pathological  states  in  other  organs,  such  as  tuberculosis,  amyloid  and 
fatty  degeneration  of  various  viscera,  dropsies,  and  edema.  Some  of 
the  cases  reported  as  syphilitic  are  doubtful.  This  is  my  opinion 
of  the  case  reported  by  Zavadski  and  Luxenbourg  {loc.  cit.),  in  which 
no  characteristic  syphilitic  lesions  are  described,  for  the  endarteritis 
and  the  small  round-cell  infiltration  may  occur  in  chronic  gastritis  of  a 
non-luetic  character.  The  patient,  a  medical  student,  had  denied 
luetic  infection. 

Syphilitic  Neoplasms  of  the  Stomach. — The  percentage  of  gastric 
gummata  occurring  in  syphilis  has  already  been  stated  in  the  results 
given  from  243  autopsies  on  syphilitics  performed  by  Chiari  {loc.  cit.). 

Gastric  gummata  have  been  described  by  Galliard  {loc.  cit.),  Comil 
{loc.  cit.),  Birch-Hirschfeld  {loc.  cit.),  Chiari  {loc.  cit.),  Wagner. (/oc. 
cit.),  Klebs  {loc.  cit.),  and  Lanceraux  {loc.  cit.).  Cornil's  case,  which 
may  be  regarded  as  typical,  was  that  of  a  woman  who  had  gummata 
both  in  the  liver  and  stomach.  That  in  the  stomach  was  located  on 
the  lesser  curvature,  and  had  the  appearance  of  a  flattened  reddish 
tumor,  two  to  five  centimeters  in  diameter.     The  gastric  gummata 


SYPHILITIC   NEOPLASMS.  603 

reported  by  Chiari  (loc.  cit.)  were  sharply  circumscribed  elevated 
swellings.  They  occur  together  with  gastric  or  intestinal  ulcers  or 
cicatrices,  and  develop  in  the  submucous  layer  as  dense,  compact, 
felt-like  masses,  formed  of  fasciculi  of  connective  tissue  infiltrated 
with  small  round  cells.  From  the  submucosa  they  advance  into  the 
serosa  and  mucosa.  The  mucosa  is  thickened,  smooth,  and  glisten- 
ing, and  of  a  pale  yellow  color.  The  muscularis  and  the  serosa  are 
also  thickened.  The  condition  of  the  gummata  will  vary  with  the 
stage  in  which  they  are  found.  In  one  case  Cornil  found  three  gum- 
mata— respectively  two,  three,  and  five  centimeters  in  diameter — 
in  the  neighborhood  of  the  pylorus.  The  mucosa  over  these  gum- 
mata was  thinned  out  and  adherent.  Lanceraux  {loc.  cit.)  found  an 
ulceration  thirty  centimeters  in  diameter  in  close  proximity  to  the 
pylorus  on  the  lesser  curvature.  The  case  was  that  of  a  man  sixty- 
six  years  old,  with  many  manifestations  of  syphilis.  The  ulceration 
had  destro^-ed  the  gastric  wall — thinned  it  down  to  a  very  delicate 
lamella.  The  nodule  was  in  a  state  of  fatty  disintegration,  and  ap- 
parently had  prevented  a  perforation  by  its  own  structure.  Birch- 
Hirschfeld's  case  occurred  in  a  new-born  infant,  with  skin  syphilis 
and  a  gumma  in  the  liver  and  lungs.  In  the  pylorus  was  a  slightly 
elevated  thick  area,  as  large  as  the  palm  of  the  hand.  It  was  of  a 
whitish  color  and  of  tolerably  firm  consistence,  formed  of  granulation 
tissues  infiltrated  with  masses  of  small  round  cells.  Weichselbaum 
{loc.  cit.)  described  two  ulcers  and  one  cicatrix  at  a  spot  where  the 
transition  of  the  fundus  into  the  pyloric  part  occurs.  One  of  the 
ulcers  had  a  triangular  shape  and  was  twelve  millimeters  long.  This 
occurred  in  a  man  twenty-five  years  old,  with  syphilitic  manifesta- 
tions of  the  cranium,  nose,  throat,  larynx,  and  liver.  Another  case 
of  Chiari's,  a  child  three  weeks  old,  with  pemphigus  syphiliticus, 
swelling  of  the  inguinal  glands,  and  fissures  in  the  lips,  tongue,  and 
penis,  showed  in  the  lungs  numerous  nodules  as  large  as  peas,  some  as 
large  as  hazelnuts.  There  was  an  induration  in  the  hilus  of  the  li\'er, 
and  a  similar  callosity  on  the  common  bile-duct,  and  also  on  the  cystic 
duct.  The  wall  of  the  gall-bladder  neck  was  strongly  infiltrated. 
The  gastric  mucosa  showed  five  plate-like  gummata.  The  gastric 
gummata  generally  soften,  break  down,  and  ulcerate;  this  has  been 
the  cause  of  assigning  all  syphilitic  ulcers  to  the  breaking  down  of 
gummata.  The  ulcer  which  arises  from  a  gumma  is  a  loss  of  sub- 
stance that  is  smaller  in  the  true  mucosa  than  in  the  submucosa. 
The  simple  perforating  gastric  ulcer  is  a  loss  of  substance  that  is 


6o4     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

greatest  in  the  true  mucosa,  becomes  smaller  in  the  submucosa,  and 
still  smaller  in  the  muscularis. 

This  gives  the  simple  gastric  ulcer  the  characteristic  terraced  ap- 
pearance, which  is  never  seen  with  a  gummatous  gastric  ulcer.  The 
edge  of  the  simple  gastric  ulcer  is  not  undermined,  but  has  the  ap- 
pearance as  if  cut  out  with  a  punch.  The  edge  of  the  gummatous 
gastric  ulcer,  however,  is  irregular,  angular,  rolled  up,  and  often  un- 
dermined. The  surroundings,  the  walls,  and  the  floor  of  the  simple 
gastric  ulcer  exhibit  no  pus  and  no  necrotic  tissue  elements ;  perhaps 
some  slight  hemorrhagic  infiltration  is  observable,  if  a  previous 
hemorrhage  has  occurred.  The  gummatous  gastric  ulcer  is  covered 
by  a  yellow,  tough,  gelatinous  deposit.  In  the  surroundings  one 
frequently  finds  gummata.  Old  and  extensive  simple  ulcers  may 
closely  resemble  gummatous  ulcers  on  account  of  the  fibrous  thicken- 
ing of  the  edges.  The  occurrence  of  gummata  in  other  parts  of  the 
digestive  tract  or  organs  may  then  decide  the  nature  of  the  gastric 
neoplasm.  Gummata  of  the  stomach,  according  to  Neumann,  are 
manifestations  of  late  lues.  The  cases  of  Birch-Hirschfeld  {loc.  cit.) 
and  Chiari  {loc.  cit.),  however,  were  inherited  syphilis. 

Diagnosis. — These  lesions  do  not  give  symptoms  sufficiently 
characteristic  to  make  their  clinical  recognition  possible.  In  pro- 
nounced syphilitics,  with  palpable  hepatic  gummata  and  stenotic 
symptoms  in  the  stomach,  antisyphilitic  treatment  may  possibly  give 
some  clue  regarding  the  nature  of  the  gastric  neoplasm. 

Hemorrhage  from  the  Stomach  as  a  Result  of  Syphilis. — This 
is  an  extremely  rare  occurrence.  Hay  em  reports  a  case  of  grave 
hematemesis  which  baffled  the  usual  treatment,  but  ceased  after  the 
administration  of  iodid  of  potash.  Gastric  hemorrhage  may  occur  as 
a  result  of  intense  passive  congestion,  caused  by  obstruction  of  the 
portal  circulation.  Hiller  {loc.  cit.)  reports  a  case  of  a  man  thirty- 
nine  years  old,  who  admitted  having  acquired  lues  in  1868.  In  the 
night  from  the  3d  to  the  4th  of  December,  1881,  he  vomited  large 
quantities  of  blood,  and  passed  blood  by  the  stool.  On  the  5th  of 
December  the  vomiting  of  bright  red  blood  was  repeated;  he  also 
had  three  passages  that  were  black  with  partially  digested  blood. 
The  gums  and  uvula  were  covered  with  numerous  radiating  scars; 
the  pharynx  showed  two  recent  scars.  In  the  nasal  partition  there 
was  an  irregular,  deepened  ulcer  with  callous  edges.  For  several 
months  there  had  been  a  purulent  offensive  discharge  from  the  nose. 
There  was  decided  enlargement  of  the  spleen  and  liver.     Several 


LITERATURE    ON    SYPHILIS    OE    THE    STOMACH.  605 

uneven  prominences  were  palpable  on  the  surface  of  the  liver.  The 
diagnosis  of  syphilis  of  the  liver  was  made,  with  passive  congestion  in 
the  spleen  and  stomach.  The  patient  recovered  under  antisyphilitic 
treatment.  It  is  impossible  to  decide  in  these  cases  whether  the 
hemorrhage  comes  from  an  ulcer,  from  hemorrhagic  erosions,  or  from 
disease  of  the  blood-vessels. 

LITERATURE 

ON   SYPHILIS   OF   THE   STOMACH. 

1.  Andral,  "  Clinique  med.,"  tome  iv,  121. 

2.  Bartumeus,  "  Gastralgia  Intermittente  Sifilitica  Accompananda  de  Vomi- 
tos  Vespertinos  y  Otros  Accidents  Especificos  Dolorosos,"  "  Revista  de  Cien- 
cias  Med.,"  Barcelona,  1878,  348. 

3.  Berthold's  "  Statistischer  Beitrag  zur  Kenntniss  des  chronischen  Magen- 
geschwiirs,"  aus  den  "  Sections-ProtokoUen  des  Patholog.  Institutes  zu  Berlin," 
1868-82,  Berlin,  1883;  Dissertation. 

4.  Bittner,  "  Centralbl.  f.  allgem.  Pathologic,"  Bd.  v,  1894,  S.  175;  also 
"  Prag.  med.  Wochenschr.,"  1893,  No.  48. 

5.  Birch-Hirschfeld,  "  Lehrbuch  der  patholog.  Anatomie,"  1885,  il,  531. 

6.  Capozzi,  II,  Morgagni,  1867,  ix,  2,  89;  Schmidt's  "  Jahrbiicher," 
cxxxv,  41. 

7.  Chiari,  "  Prag.  med.  Wochenschr.,"  1885,  No.  47. 

8.  Chiari,  "  International.  Beitrag  z.  Wissenschaft ;  Medicin,"  Rudolf  Vir- 
chow  gewidmet,  1891,  Bd.  11. 

9.  Cornil,  "  Lemons  sur  la  Syphilis,"  1879,  4o6;  and  "  Manuel  de  I'Histolog. 
Patholog.,"  1882,  II,  296. 

10.  Dieulafoy,  "Syphilis  de  I'estomac,"  Acad,  de  Med.,  17.  Mai,  1898. 

11.  Dubuc,  "  Un  cas  de  syphilis  de  I'estomac,"  "  Soc.  de  Med.  de  Paris," 
28.  Juin,  1898. 

12.  Fauvel,  "  Bullet,  de  la  Societe  d'Anatom.,"  1858. 

13.  Flexner,  S.,  "  Gastric  Syphilis,  with  the  Report  of  a  Case  of  Perforating 
Syphilitic  Ulcer  of  the  Stomach,"  "Am.  Jour,  of  the  Med.  Sciences,"  Oct., 
1898. 

14.  Fournier,  "  Notes  sur  Certains  Cas  Curieux  de  Boulimie  et  de  Polydipsia 
d'Origine  Syphillitique,"  "  Gaz.  hebdomadaire  de  Med.  et  de  Chirurg.,"  Paris, 
1871,  Nos.  I  and  2;  "Gaz.  des  Hopitaux,"  Paris,  1871,  Nos.  109,  no,  112. 

15.  Galliard,  "Syphilis  Gastrique  et  Ulcere  Simple  de  I'Estomac,"  "  Archiv 
Generales  de  Medecme,"  1886,  pp.  65-83. 

16.  Hayem,  G.,  Hayem  et  Tissier,  "  De  la  Syphilis  de  I'lntestin,"  "  Revue 
de  Med.,"  Paris,  1889,  231. 

17.  Hiller,  "  Monatshefte  f.  prakt.  Dermatalogie,"  1882,  i,  97  ff. 

18.  Von  Jaksch,  cit.  nach  Bamberger,  "  Krankheiten  des  chylopoetischen 
Systems,"  "  Handb.  d.  spec.  Pathologic  u.  Therapie,"  von  Virchow,  vi,  i. 
Abth.,  280. 

19.  JuUien,  L.,  "  Traite  Pratique  des  Malad.  Vener.,"  1879,  P-  ^^S- 

20.  Klebs,  "  Pathologische  Anatomie,"  1869,  i,  262,  263. 

21.  Lanceraux,  "Traite  Historiquc  et  Pratique  de  la  Syphilis,"  Paris,  1873, 
249. 

40 


6o6  BKNIGN   TUMORS    01^   THE   STOMACH. 

22.  Lanceraux,  "  Traite  de  la  Syphilis,"  1874,  248. 

23.  Lang,  T.,  "  Zur  Lehre  von  der  Eingeweidesyphilis."     Sonderdruck  der 
"Wiener  med.  Presse,"  1885,  No.  11. 

24.  Lang,  T.,  "Eingeweidesyphilis,"  "  Wien.  med.  Presse,"  1885,  No.  11. 

25.  Mauriac,  "  Syph.  tert.,"  p.  723. 

26.  Neumann,  in  "  Nothnagel's  specielle  Patholog.  u.  Therapie,"  Bd.  xxiii, 
Syphilis,  S.  351. 

27.  Nolte,    "  Ueber    die    Haufigkeit    des   Magengeschwiirs  in    Miinchen," 
Miinchen,  1883  ;  Dissertation. 

28.  Orth,  "  Lehrbuch  d.  speciellen  pathol.  Anatomie,"  Berlin,   1887,  i,  S. 

709.  744- 

29.  Oser's    "  Vierteljahresschrift    fiir    Dermatologie  und   Syphilis,"     1871, 
No.  27. 

30.  Rosanow,  v.,  "  Magengeschwiir  syphilitischen  Ursprungs,"  "La  Sem- 
aine  Medicale,"   1890,  No.  43. 

31.  TuUio,  "  Contributo  alio  Studio  delle  Lesioni  Funzionale  Gastriche,  per 
Sifilide  edei  coro  Magri  curative,"  "  Polyclinica,"  xv,  Giugni,  1894. 

32.  Virchow,  "  Handb.  der  spec.  Pathol.  undTher.,"  xi,  i,  S.  71,  78. 

33.  Wagner,  "  Das   Syphilom,"    "  Archiv   der  Heilkunde,"   1863,    Bd.   iv, 
225  und  226,  369. 

34.  Weichselbaum,  "  Bericht  d.  Rudolfspitals  in  Wien,"  1883,  S.  383. 

35.  Zavadski  and  Luxembourg,  "Gaz.  Lekaroka,"   1893,  vol.  xiii,  p.  1233, 
et  seq. 

36.  "  Jahresbericht  der  k.-k.  Krankenanstalt  Rudolf-Stiftung,"  1883,  383. 

37.  Flexner,    Simon,    "  Gastric  Syphilis  ;  A  Case   of  Perforating   Syphilitic 
Ulcer  of  the  Stomach,"  "  Am.  Jour.  Med.  Sciences,"  October,  1898. 


CHAPTER  VI. 

BENIGN  TUMORS  OF  THE  STOMACH. 

Myomata.  —  Fibromata.  — Lipomata.  —Polypi.  — Myxomata. — Papil- 
lomata. — Lymphadenomata. — Pedunculate  Tumors. — For- 
eign Bodies. — Gastroliths .—Hypertrophic  Stenosis 
of  the  Pylortis. 

The  stomach  may  be  the  seat  of  a  great  diversity  of  tumors.  A 
neoplasm  that  can  be  determined  by  palpation,  however,  is,  as  a  rule, 
a  carcinoma.  Benign  tumors  are  very  rare,  and  their  clinical  history 
does  not  present  any  great  interest.  But  occasionally  they  may 
become  the  cause  of  errors  in  diagnosis.  This  reason  obliges  me  to 
say  a  few  words  about  them,  as  well  as  of  other  foreign  bodies  and 
gastroliths  which  are  liable  to  occur  in  the  stomach. 


POLYPI — MUCOUS   POLYPI.  607 

Myomata,  lipomata,  papillomata,  and  lymphadenomata  have  been 
found  in  the  stomach. 

In  acute  toxic  gastritis  caused  by  the  ingestion  of  corrosive  subli- 
mate, calcareous  masses  may  develop  in  the  depths  of  the  mucous 
membrane.  In  comparing  simple  chronic  gastritis  with  gastric 
tuberculosis  we  have  shown  that  in  the  former  the  glands  were  capa- 
ble of  undergoing  a  cystic  degeneration  more  or  less  pronounced. 
Aneurysms  of  vessels  in  the  walls  of  the  stomach  have  also  been 
described. 

Polypi.— Papillomata  arising  from  the  mucous  membrane  some- 
times form  very  well-developed  villosities  in  the  pyloric  region.  In 
their  interior  one  finds  a  very  fane  fibrillous  network,  formed  by  the 
prolongations  of  branched  cells ;  their  surface  is  covered  with  cylin- 
drical epithelium. 

Polypi  may  develop  from  myomata,  lipomata,  fibromata,  and  papil- 
lomata. They  vary  in  size  from  that  of  a  pea  to  that  of  a  walnut. 
They  may  be  pedunculated  or  attached  by  broad  bases.  The  term 
polypus  is  only  descriptive,  and  not  so  important,  anatomically,  as 
the  terms  for  other  gastric  neoplasms.  In  the  structure  of  polypi  at 
times  the  connective  tissue,  at  others  the  glandular  element,  pre- 
dominates. They  might,  therefore,  be  classed  logically  among  the 
fibromata  and  adenomata.  They  may  present  smooth,  warty,  or 
villous  surfaces,  the  latter  resembling  the  surface  of  a  raspberry  or 
at  times  of  cauliflower. 

Villous  growths  presenting  warty  surfaces  and  a  papillomatous 
structure  are  classed  among  the  fibromata.  They  are  covered  by  a 
single  layer  of  cylindrical  cells. 

Mucous  Polypi. — Cornil  ("Gaz.  des  Hopitaux,"  1864,  No.  20)  has 
brought  to  light  two  cases  of  mucous  polypi  which  had  not  mani- 
fested any  symptoms  during  life.  In  one  of  these  cases  the  red, 
mammillated,  in  places  slate-colored,  stomach  presented  eight  vege- 
tations, from  the  size  of  a  grain  of  wheat  to  that  of  a  bean,  which  had 
their  seat  in  the  vicinity  of  the  pylorus.  These  vegetations  were 
soft,  rosy,  and  injected  with  blood;  their  surface  was  irregularly 
mammillated,  and  they  were  formed  exclusively  at  the  expense  of  the 
mucous  membrane.  In  the  other  case  there  existed  only  one  ped- 
unculated polypus,  rounded  like  a  cauliflower,  and  as  large  as  a  hazel- 
nut. This  tumor,  formed  at  the  expense  of  the  mucous  membrane 
and  of  the  submucosa,  was  very  vascular  at  its  center.  Tambl 
("Beobachtungen  aus  dem  Franz  Joseph  Kinderspital,"  Prag,  1S60, 


6o8  BENIGN   TUMORS    OF    THE    STOMACH. 

p.  376)  has  described  a  tumor  as  large  as  a  pigeon's  egg,  extending 
three  centimeters  along  the  fundus  of  the  stomach,  and  covered  by 
the  mucous  membrane,  which  had  become  thin ;  no  sign  had  revealed 
its  existence  during  life.  Debove  found  a  mucous  polypus  by  means 
of  the  tube,  in  a  patient  suffering  from  nervous  dyspepsia. 

Rokitansky  attributed  the  formation  of  these  tumors  to  chronic 
gastritis ;  they  would  thus  develop  around  the  glands  of  the  papillae 
in  unusual  numbers  and  sizes.  Wilson  Fox  also  admits  the  part 
played  by  inflammation  in  the  genesis  of  these  polypi.  Canus  Govig- 
non  ("Polypes  de  I'Estomac,"  These,  Paris,  1883)  attributes  a 
certain  influence  to  alcoholism.  These  polypi,  whatever  may  be 
their  structure,  are  somewhat  rare.  The  first  case  was  pointed  out  by 
Cruveilhier  ("Atlas  de  I'Anatomie,"  xxx  livraison.  Fig.  2,  p.  2);  the 
stomach,  the  drawing  of  which  he  gives,  contained  ten  pedunculate 
excrescences,  one  of  which  obliterated  the  pylorus.  Andral  ("Clin- 
ique  Medicale,"  tome  11)  in  one  case  discovered  laminated  structures 
analogous  to  the  gastric  mucosa  of  ruminants.  Ripault  (1833),  Mer- 
cier  (1887),  Castilhes  (1843),  Earth  (1845),  Richard  (1846),  lyCudet 
(1847),  Earth  (1849),  have  reported  a  certain  number  of  cases  of  the 
same  character.  Ebstein  ("Arch.  p.  Anat.  u.  Physiol.,"  1864)  has 
collected  all  these  observations,  and  has  added  14  cases  which  he  had 
himself  obtained  from  600  autopsies.  Of  the  24  cases  thus  collected, 
1 5  occurred  in  men  and  8  in  women ;  in  i  case  the  sex  of  the  patient  is 
not  mentioned .  The  frequency  of  these  tumors  increases  after  forty 
years ;  in  half  the  cases  they  are  isolated ;  in  i  case  there  were  50  of 
them,  and  in  2  cases  there  was  a  number  varying  from  150  to  200. 
Their  form  is  variable — they  are  rounded,  club-shaped,  cylindrical, 
ramified;  their  color  depends  on  their  vascularization;  frequently 
they  are  pigmented.  The  mucous  membrane  which  covers  them  is 
sometimes  entirely  smooth,  sometimes  villous,  or  thickened.  They 
are  usually  located  at  the  pylorus,  and  their  size  is  in  inverse  ratio  to 
their  number. 

Lipoma  (Murray,"Fatty  Tumor  in  Wall  of  the  Stomach,"  "Pathol. 
Tr.,"  vol.  XI,  1890). — The  lipoma  is  also  very  rare.  Starting  from 
the  submucosa,  it  sometimes  makes  a  projection  toward  the  gastric 
cavity,  pushing  back  the  mucous  membrane  which  continues  to  cover 
it,  but  grows  thinner  in  proportion  as  the  tumor  increases;  some- 
times it  pushes  aside  the  muscular  fibers  and  succeeds  in  making  a 
hernia  under  the  serosa.  A  large  tumor  of  this  kind  might  cause 
digestive  troubles  by  the  dragging  of  its  weight  on  the  wall  of  the 


MYOMA — LYMPHADENOMA.  609 

stomach,  but  the  rareness  of  these  cases  interferes  with  an  exact 
knowledge  and  description  of  their  s^^mptoms.  Orth  has  observed 
lipomata  growing  from  the  serosa  in  a  pendulous  manner  (/.  c,  S.  71 7). 

Myoma. — The  myoma  develops  in  the  interior  of  the  muscular 
layer,  gradually  projects  under  the  mucous  membrane,  and  occa- 
sionally ends  by  forming  polypi — sometimes  isolated,  sometimes  in 
numbers.  These  tumors  do  not  differ  in  a  histological  point  of  view 
from  those  which  may  be  found,  for  example,  in  the  uterus,  but  their 
size  rarely  exceeds  that  of  a  pea  or  a  cherry.  Their  development  is 
not  accompanied  by  any  symptoms,  and  they  are  rarely  discovered 
at  the  autopsy.      (Myoma,  see  Virchow-Onkol,  iii,  126.) 

Symptoms. — The  symptomatology  of  these  tumors  is  variable. 
Sometimes  they  become  ulcerated,  and  Rondeau  ("Presse  med. 
Beige.,"  No.  18,  1881)  has  pointed  out  a  case  where  their  presence 
was  revealed  by  serious  hemorrhages;  naturally,  the  observer  was 
not  able  to  diagnose  the  cause  of  this  hematemesis.  At  other  times, 
as  in  the  case  of  Cruveilhier's  patient,  the  tumor  may  obstruct  the 
pylorus  and  cause  a  dilation  of  the  organ.  Bernabes  ("Rivista 
Clinica  di  Bologna,"  Juillet  et  Auot,  1882)  had,  in  this  way,  the  op- 
portunity of  observing  a  woman  seventy  years  old  who,  for  a  long 
time,  had  vomited  a  few  hours  after  meals,  and  experienced  sharp 
epigastric  pains,  in  the  absence  of  characteristic  symptoms.  At  the 
autopsy  there  was  found  a  polypus  of  six  or  eight  centimeters,  im- 
planted on  the  anterior  surface  of  the  stomach,  five  centimeters  from 
the  pylorus.  Five  other  smaller  polypi  were  scattered  on  the  pyloric 
antrufn  and  along  the  greater  curvature  (Bruman,  "Th.  de  Paris," 
1883;  Brissaud,  "Arch.  Gen.  de  Med.,"  1885;  Marfan,  "Th.  de 
Paris,"  1887;  Menetrier,  "Arch,  de  Phys.,"  15.  Fevrier,  1888). 

Lymphadenoma. — The  stomach  ma}^  also  be  the  seat  of  lymphoid 
tumors.  These  likewise  constitute  a  pathological  rarity.  Pitt 
("Pathol.  Trans.,"  vol.  xi,  1890)  has  reported  one  case,  and  states 
that  he  has  been  unable  to  find  more  than  seventeen  in  the  literature 
on  the  subject.  The  patient  had  succumbed  to  phenomena  which 
were  all  attributed  to  a  tumor  of  the  lungs,  and  to  an  empyema  of  the 
left  pleura.  Soft  nodules  were  scattered  over  the  stomach  and  intes- 
tines, which  had  perforated  the  mucous  membrane,  or  had  made 
greater  or  lesser  projections  at  its  surface;  histologically,  all  the 
characteristics  of  lymphadenoma  were  exhibited.  The  spleen,  the 
mesenteric,  and  the  bronchial  ganglia  were  invaded ;  the  liver  and  the 
kidneys  were  not  affected,  however.     The  neoplasm  develops  in  the 


6lO  BENIGN   TUMORS    OF    THE    STOMACH. 

mucosa  and  submucosa,  and  forms  tumors  projecting  into  the  cavity. 
On  the  other  hand,  at  times  the  serosa  is  first  attacked.  The  muscu- 
lar stratum  then  becomes  more  or  less  affected  by  distention,  and  a 
dilation  of  the  organ  becomes  evident.  In  other  cases  the  tumors 
which  project  into  the  gastric  cavity  become  ulcerated,  and  the 
patient  succumbs  to  a  hematemesis,  as  in  Reimer's  observation 
("Deut.  Arch.  f.  klin.  Med.,"  Bd.  xxxin,  S.  632,  1879).  ^^  these 
phenomena  are  always  added  a  diarrhea  of  var)- ing  seriousness ;  but 
when  the  tumors  remain  limited  to  the  stomach,  health  may  be  little 
affected  b}^  it.  Anatomically,  one  finds  around  the  base  of  the  tumor 
a  hardening  of  the  mucous  membrane;  the  glands  aft'ected  are  in 
fatt}^  degeneration,  while  at  their  periphery  there  exists  a  character- 
istic reticulated  tissue.  The  degenerated  glands  finally  disappear, 
and  there  remains  nothing  more  than  the  reticulated  tissue  of  the 
tumor. 

Pedunculated  adenomata,  attaining  the  size  of  an  apple,  have 
been  observed,  which  were  composed  exclusively  of  tortuous,  irregu- 
larly dilated  gland  tubules.  Tumors  may  occur  in  the  stomach  as 
well  as  in  the  intestines,  which  anatomically  and  clinically  must 
be  considered  cancers,  and,  having  a  pronounced  glandular  structure 
are  designated  as  destructive  or  malignant  adenomata  or  adenocarci- 
nomata.  The  case  reported  by  Pitt  {I.  c.)  is  suggestive  of  this  type. 
They  have  been  considered  under  the  malignant  tumors. 

Cysts. — Retention  cysts  of  the  gastric  glands  occur  in  "gastritis 
polyposa  "  and  polypoid  hypertrophy.  Ruysch  ("Adversaria  Ana," 
tome  III,  p.  I,  Dec,  1732)  described  a  gastric  dermoid  cyst  contain- 
ing hair.  Engel-Reimers  ("Deut.  Arch.  f.  klin.  Med.,"  xxiii,  p.  632, 
1879)  describe  a  multilocular  lymphangioma  occurring  in  the  outer 
gastric  wall  beneath  a  chronic  ulcer  of  the  lesser  curvature.  This 
cyst  contained  a  milky  liquid,  produced  b}^  stasis  of  lymph  in 
consequence  of  occlusion  through  inflammatory  processes  in  the 
vicinity  of  the  ulcer.  Albers  ("Erlauterungen,"  iv,  p.  151)  men- 
tions a  cyst  2\  inches  long  found  on  the  lesser  gastric  curvature 
in  a  child. 

Foreign  Bodies. — Foreign  bodies  are,  in  certain  cases,  capable  of 
simulating  a  tumor,  both  by  the  subjective  S3^mptoms  which  they 
cause,  and  b}'  the  deception  to  which  they  give  rise  on  palpation. 
A  patient  of  Baillarger's  ("Union  Med.,"  No.  48,  1874)  had  kept  in 
his  gastric  cavity  for  six  years  a  zinc  fork ;  an  epileptic,  cited  by  Fo- 
ville  ("Gaz.  hebd.  de  Med.  et  de  Chir.,"  No.  18,  1874),  had  swallowed 


FOREIGN    BODIES    IN   THE    STOMACH.  6 II 

28  dominoes;  an  ecclesiastical  patient  thus  preserved  his  rosan,-  in 
his  stomach  for  a  time.  Labbe  ("De  I'Acad.  des  Sciences,"  21  Avril, 
1866)  extracted  a  fork  by  gastrotomy.  A  sailor  ("Med.  Chir.  Trans- 
act.," vol.  XII,  p.  72),  cited  by  Ewald,  in  imitation  of  a  juggler,  swal- 
lowed 35  small  knives,  and  succumbed  only  a  long  time  afterward  to 
digestive  troubles.  There  were  found  at  the  autopsy  32  blades, 
more  or  less  corroded :  30  in  the  stomach  and  2  in  the  intestines.  It 
is  unlikely,  however,  that  such  objects  as  these  could  produce  the 
signs  of  tumors. 

Schonborn  ("Berl.  klin.  Wochenschr.,"  Nr.  17,  1883,  und  "Arch, 
f.  klin.  Chirurgie,"  Bd.  xxix,  S.  609,  1883)  has  reported  an  obser\-a- 
tion  in  which  a  gastrolith  (movable  tumor)  was  discovered  in  a  girl 
fifteen  years  old,  occupying  the  left  half  of  the  abdomen;  it  was 
easily  pushed  back  under  the  left  edge  of  the  ribs,  and  very  painful, 
both  spontaneously  and  on  palpation.  The  patient  grew  thin,  would 
not  tolerate  any  food,  and  her  state  became  so  serious  that  it  was  de- 
cided to  perform  a  laparotomy,  after  having  hesitated  for  a  long  time 
between  the  diagnosis  of  a  movable  kidne}^  and  that  of  movable 
spleen. 

The  opening  being  made,  the  stomach  was  found  distended ;  it  was 
cut  into,  and  a  mass  of  281  gm.  was  found,  formed  by  a  network  of 
short  hairs,  and  molded  to  the  form  of  the  gastric  cavity.  The  pa- 
tient then  confessed  that  four  years  before  she  had  swallowed  the  hair 
in  order  to  "make  her  voice  clear."  After  this  case,  Schonborn  made 
a  careful  collection  of  the  known  cases,  and  found  seven  of  them,  the 
oldest -of  which  dates  back  to  1777.  These  cases  include  six  women 
and  one  boy ;  none  were  insane.  All  these  subjects  had  died ;  some 
from  peritonitis  through  perforation,  others  from  uncontrollable 
vomiting.  One  case  ended  in  hematemesis,  and  Russel  ("Med. 
Times  and  Gazette,"  June  i6,  1869),  who  published  it,  reports  that 
the  tumor  weighed  four  pounds  seven  ounces,  was  twelve  inches  long, 
five  inches  broad,  and  four  inches  thick.  Never  before  had  there 
been  digestive  troubles,  and  it  had  been  supposed  that  it  was  a  tumor 
of  the  spleen.  In  the  observation  of  Inmann  ("Med.  Times  and 
Gazette,"  July  3,  1869)  the  mass  of  hair  was  equally  large.  Best 
("  Brit.  Med.  Jour.,"  Dec.  11,  1869)  reported  a  case  of  a  woman  thirty 
years  old  who,  for  sixteen  years,  had  complained  of  pains  after  meals, 
and  had  frequent  vomitings,  occasionally  streaked  with  blood.  For 
six  years  the  pain  had  been  almost  intolerable,  and  hindered  the 
patient  from  giving  herself  to  any  occupation.     At  the  epigastrium  a 


6l2  BE^NIGN   TUMORS    OF   THE    STOMACH. 

movable  tumor  was  discovered,  not  sensitive  to  pressure,  smooth, 
hard,  extending  from  the  right  hypochondriac  region  to  the  left  of  the 
umbilicus,  the  prolonged  palpation  of  which  caused  emesis.  Peri- 
tonitis from  perforation  ended  the  case.  The  stomach  and  the 
esophagus  were  filled  with  a  quantity  of  hairs,  some  of  which  were 
from  ten  to  twelve  inches  long,  and  which  altogether  weighed  thirty 
ounces.  The  patient  had  acquired  the  habit  of  swallowing  her  hair 
fifteen  years  before.  Since  Schonborn's  notice,  Kooyker  ("Zeit- 
schrift  f.  klin.  Med.,"  xiv,  S.  203,  1888;  also  "Weekbl.  v.  d.  Nederl. 
Tydsch.  v.  Geneesk.,"  December,  1887)  has  reported  the  case  of  an 
individual  fifty-two  years  old  who,  after  having  presented  phenom- 
ena of  cachexia,  with  hematemesis,  succumbed  at  the  end  of  three 
years  of  sickness.  During  life  a  tumor  the  size  of  a  small  apple  had 
been  felt  at  the  epigastrium ;  and  displacement  of  the  spleen,  a  float- 
ing kidney,  a  cancer  of  the  stomach,  and  a  cancer  of  the  colon  were 
suspected,  one  after  the  other.  On  opening  the  stomach  at  the  au- 
topsy a  renal-shaped  foreign  body  was  found,  18  by  8  cm.,  weighing 
885  gm. ;  two  other  masses  were  also  discovered,  the  size  of  a  hen's 
egg.  On  examination  with  the  microscope,  these  bodies  showed 
some  grains  of  starchy  matter  and  some  vegetable  cells,  some  of  which 
contained  chlorophyl,  but  no  trace  of  animal  substances.  This  case 
is  analogous  to  that  of  Capelle's  ("Jour,  de  Med.  de  Bruxelles,"  Fevr., 
1 861),  who  treated  a  woman  forty-three  years  old  for  a  tumor  of  the 
stomach,  who  had  been  ill  for  a  long  time.  The  symptoms  were 
emesis,  intense  gastric  pains,  and  constipation.  The  tongue  was 
coated,  palpitations  frequent,  the  pulse  small  and  weak.  Under  the 
xyphoid  cartilage  was  found  a  hard,  immovable  tumor  as  large  as  a 
pigeon's  egg,  which  disappeared  when  vomitings,  more  violent  than 
others,  had  caused  the  expulsion  of  a  foreign  body  of  nine  cubic  centi- 
meters, half  softened,  and  formed  exclusively  of  vegetable  debris. 
The  patient  recovered.  Lastly,  Bollinger  ("Miinchener  med.  Woch- 
enschr.,"  Nr.  22,  1891)  published  the  case  of  a  girl  sixteen  years  old  in 
whom  there  existed  a  hairy  tumor  which  caused  death  by  inanition. 
A  malignant  tumor  had  been  suspected,  and  there  was  found  in  the 
stomach  and  in  the  dilated  duodenum  a  tumor  55  cm.  long  by  1 1  cm. 
broad,  and  28  cm.  in  circumference,  formed  by  500  gm.  of  hairs,  which 
measured  about  10  cm. 

The  presence  of  foreign  bodies  in  the  stomach  may  give  rise  to  the 
following  signs  and  symptoms :  The  organ  dilates,  becomes  displaced 
(Russel) ;  the  mucous  membrane  atrophies ;  the  pj^lorus  ma}^  be- 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS.         613 

come  expanded  through  muscular  efforts  to  pass  out  the  foreign  body, 
which  will  act  as  a  ball  valve  when  expulsion  is  impossible ;  the  peptic 
secretions  disappear;  the  erosions  allow  the  escape  of  blood  in  more 
or  less  abundance,  and  the  patients  usually  succumb  to  a  cachexia, 
since  in  the  end  alimentation  becomes  impossible. 

Therapeutic  measures  are  useless  in  these  cases.  An  exploratory 
laparotomy  is  the  only  rational  procedure. 

Erlach  removed  a  myoma  from  the  stomach  weighing  5400  gm. 
("Centralbl.  f.  allg.  Patholog.,"  Bd.  vi,  1895,  S.  240).  In  the  same 
journal  (vol.  vi,  S.  717)  Hansemann  is  reported  as  having  found  four 
peculiar  tumors  in  the  stomach  :  (i)  A  myoma  with  cystic  degenera- 
tion; (2)  a  sarcoma  with  hyaline  degeneration  and  containing  large 
calcareous  bodies ;  (3)  a  tumor  of  myxomatous  nature ;  (4)  a  tumor 
composed  of  finely  fibered  connective  tissue,  inclosing  hollow  spaces 
which  contained  cells  in  a  state  of  fatty  degeneration,  simulating  the 
cortical  substance  of  the  adrenal  bodies.  Professor  Julius  Schreiber 
reported  a  case  of  phytobezoar  composed  of  the  fibrous  roots  of  a 
plant  ("Schwarzwurzel  "),  which  is  a  popular  remedy  for  all  sorts  of 
ailments  in  Germany.  The  patient  was  a  female  peasant  forty-five 
years  old.  The  tumor  very  much  resembled  a  floating  spleen  or 
malignant  neoplasm.  The  diagnosis  was  correctly  made  and  the 
woman  successfully  operated  upon  by  von  Eiselberg  ("Mittheil.  a. 
d.  Grenzgebieten  d.  Medicinu.  d.  Chirurg.,"  Bd.  i,  1896,  S.  729). 

In  the  "Jour,  of  the  American  Medical  Assoc,"  March  5,  1898, 
A.  H.  Meisenbach  ably  reviews  the  literature  on  gastrotomy  for 
removal  of  foreign  bodies  in  the  stomach. 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

Stenosing  gastritis,  hypertrophic  stenosis  of  the  pylorus,  is  a  thicken- 
ing of  the  tissue  about  the  pyloric  region,  caused  by  certain  forms  of 
chronic  gastritis.  The  consequences  of  this  obstruction  and  con- 
striction may  be  and  generally  are  as  serious  as  if  the  pylorus  was 
stenosed  by  malignant  neoplasm ;  except  that  in  the  former  case  the 
obstruction  may  be  radically  removed  by  operation,  which  is  doubtful 
in  cases  of  carcinoma  or  sarcoma.  The  condition  was  known  to  Cru- 
veilhier  and  Andrae.  In  England  the  disease  has  been  described  by 
Brinton,  Bennett,  Habershon,  Handheld  Jones,  and  Hughes;  and  in 
this  country  by  Einhorn,  W.  H.  Welch,  and  the  author. 

In  the  literature  of  the  subject  thus  far  presented  one  can  distin- 


6 14  BENIGN   TUMORS    OF    THE    STOMACH. 

guish  three  similar  types  of  this  affection:  In  the  first  place,  (i)  gas- 
tric cirrhosis,  the  "linitis  plastica"  of  Brinton.  In  this  disease  the 
normal  tissue  of  the  gastric  walls  is  replaced  by  proliferated  fibrillar 
connective  tissue,  which  causes  a  marked  reduction  in  the  size  of  the 
organ.  (2)  The  sclerosing  gastritis  of  the  French  authors,  first  de- 
scribed by  Hanot  and  Gombault  in  1882,  and  later  by  Dubujadoux 
and  von  Kahlden.  This  disease  {gastrite  chronique  avec  sclerose  sous 
muqueuse  hypertrophiqtte)  is  characterized  by  changes  in  the  other 
viscera,  particularly  in  the  liver,  pancreas,  kidneys,  and  especially  in 
the  omentum.  (3)  Congenital  hypertrophic  pyloric  stenosis.  Two 
cases  belonging  to  this  class  were  reported  to  the  Association  of  Amer- 
ican Physicians  in  May,  1898,  by  Adler  and  Meltzer.  This  third  type 
has  no  direct  bearing  upon  the  etiology  of  the  benign  stenosis  of 
adults.  We  are  concerned  here  only  with  types  (1)  and  (2).  The 
symptomatology  of  the  sclerosing  gastritis  of  Hanot  and  Gombault 
and  of  the  gastric  cirrhosis  of  Brinton  is  quite  obscure,  and  it  is  proba- 
ble that  it  is  hardly  ever  diagnosed  with  certainty.  In  1893  Tilger 
gave  a  historical  review  of  our  knowledge  of  stenosing  pyloric  hyper- 
trophy ("Vir chow's  Archiv,"  Bd.  cxxxii,  S.  290). 

A  very  exact  and  scientific  presentation  of  the  subject  from  the 
clinical  as  well  as  from  the  pathological  standpoint  has  been  given  by 
Lebert  (/.  c),  who  gives  an  account  of  six  personal  observations  with 
the  results  of  the  autopsies.  Einhorn  reported  four  cases  in  January, 
1895  ("N.  Y.  Medical  Record"),  which  recovered  after  operation; 
and  six  other  cases  in  which  either  surgical  interference  was  refused 
or  the  patient  temporarily  improved  by  other  methods,  but  the  diag- 
nosis of  benign  stenosis  appeared  to  him  quite  certain.  Personally,  I 
have  observed  a  benign  hypertrophy  of  the  pylorus  in  four  patients. 
The  following  is  a  typical  case :  A  white  laborer  had  suffered  from 
motor  insufficiency,  absence  of  HCl  and  ferments,  and  presence  of 
lactic  acid  for  three  years.  I  was  on  three  occasions  able  to  demon- 
strate a  stenosis  at  the  pylorus  by  my  method  of  duodenal  intubation. 
Operation  was  strongly  advised,  but  as  it  was  repeatedly  refused,  an 
attempt  was  made  to  dilate  the  pylorus  by  means  of  larger  and  larger 
sounds  introduced  according  to  my  system.  The  patient  was  unable 
to  remain  under  hospital  treatment  continuously,  and  while  the 
pyloric  dilation  by  means  of  sounds  rendered  the  pylorus  sufficiently 
permeable,  it  inevitably  contracted  again  within  eight  to  ten  weeks 
after  cessation  of  treatment.  The  patient  finally  succumbed  to  his 
disease,  and  at  the  autopsy  I  found  that  the  wall  of  the  pylorus  meas- 


TYPICAL    CLINICAL    HISTORY.  615 

ured  in  the  fresh  state  2.3  cm.  in  thickness.  All  of  the  layers  of  the 
pyloric  structure  were  thickened,  but  the  true  muscularis  and  the 
muscularis  mucosae  showed  the  greatest  increase.  Next  in  thickness 
was  the  submucosa,  while  the  peritoneal  layer  was  only  slightly  thick- 
ened. The  true  mucosa  had  disappeared  entirely  from  the  pyloric 
region.  In  cutting  a  piece  one  millimeter  in  thickness  into  serial 
sections,  I  could  not  discover  even  remnants  of  gastric  glands.  In 
Lebert's  case  there  was  still  some  glandular  layer  left,  which  was 
being  pressed  upon  by  connective-tissue  proliferation.  The  greatest 
amount  of  work  in  the  expulsive  efforts  of  the  stomach  falls  to  the 
pylorus  and  the  antrum  pylori  immediately  preceding  it.  This  re- 
gion is  naturally  prone  to  muscular  hypertrophy.  The  special  incen- 
tive cause  in  these  cases  is  a  proliferating  gastritis  resulting  in  a 
hyperplastic  inflammation,  expressing  itself  most  intensely  in  the 
pyloric  antrum  and  sphincter,  because  all  of  the  layers  of  the  stomach 
except  the  glandular  layer  are  most  abundantly  developed  in  this 
neighborhood. 

Boas  very  aptly  calls  the  catarrhal  inflammation  resulting  in  this 
condition  a  stenosing  gastritis,  to  which  designation  no  objection  can 
be  found  because  hypertrophy  of  the  pylorus  may  occur  under  a 
variety  of  circumstances — for  instance,  corrosive  agents  may  trau- 
matically  injure  the  pylorus,  and  the  hypertrophic  process  may  also 
arise  from  an  ulcer.  Pathologically,  it  is  a  chronic  hypertrophic  gas- 
tritis. Hirsch  (/.  c.)  has  reported  a  case  of  pyloric  stenosis  caused  by 
a  benign  tumor  that  had  originated  from  a  peptic  ulcer.  Another 
fact  justifying  the  nomenclature  of  Boas  is  that  the  symptomatology 
of  chronic  gastritis  generally  precedes  the  phenomena  of  this  kind  of 
stenosis  for  a  long  time.  Boas  reports  three  cases  ("Archiv  f.  Ver- 
dauungskrankh.,"  Bd.  iv,  S.  47),  but  he  is  evidently  mistaken  when 
he  asserts  that  neither  Einhorn  nor  the  author  consider  benign  pyloric 
stenosis  in  our  works,  or  that  his  three  cases  are  the  first  of  their  kind 
that  have  ever  been  cured  (/.  c,  p.  49). 

Before  proceeding  to  a  consideration  of  the  diagnostic  value  of  the 
prominent  symptoms,  a  clinical  history  of  a  second  case  from  our 
clinic  will  be  in  order. 

Mr.  W.  L,,  age  thirty-eight,  sick  since  February,  1892.  Presents  himself  for 
treatment  June,  1892.  His  suffering  began  with  pressure,  fullness,  and  disten- 
tion in  the  stomach.  Bowels  were  at  that  time  regular,  and  appetite  was  good. 
After  the  first  six  months  of  his  suffering  he  had  an  interval  of  four  months  in 
which  he  was  comparatively  well,  when  a  relapse  of  the  symptoms  of  gastritis 


6l6  HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS. 

occurred,  ascribed  to  the  ingestion  of  crabs.  In  January  of  1893  he  consulted 
the  author  again,  and  was  then  suffering  much  from  pain  in  the  stomach  after 
meals,  and  occasional  attacks  of  vomiting  following  immediately  after  meals. 
An  examination  of  the  peristalsis  of  the  stomach  showed  that  at  this  time  it  was 
in  a  fairly  good  condition — no  remnant  of  the  meal  of  the  previous  evening 
could  be  found  before  breakfast  the  following  morning.  The  contents  of  the 
stomach  before  breakfast  consisted  of  from  20  to  50  c.c.  of  liquid  containing 
much  mucus,  and  showing  presence  of  free  HCl,  but  no  food  remnants. 
Results  of  chemical  analysis  (Salzer  double  test-meal)  :  Presence  of  traces  of 
meat,  egg,  bread  from  the  larger  meal  taken  five  hours  before  ;  no  sarcinse,  no 
Oppler-Boas  bacilli ;  total  acidity,  40  ;  free  HCl,  24!;  combined  HCl,  12.  For 
the  pain  and  vomiting  the  patient  was  put  on  a  milk  diet,  and  small  doses  of 
codein.  This  was  followed  by  prompt  improvement,  the  patient  returning  to 
work.  Six  months  later  (July,  1893)  the  patient  returned  suffering  from  a 
repetition  of  the  symptoms,  which  had  returned  intensified.  The  main  suffer- 
ing was  due  to  vomiting  and  pain.  He  was  taught  to  use  the  stomach-tube 
himself,  because  now  there  were  very  evident  signs  of  stagnation,  as  decom- 
posed remnants  of  previous  meals  were  found  every  morning  before  breakfast. 
These  remnants  were  the  more  abundant  the  more  solid  food  the  patient  had 
taken,  but  if  the  diet  had  existed  exclusively  of  milk  and  egg-albumen,  or  very 
finely  scraped  beef,  no  food  remnants  were  found  in  the  stomach  the  following 
morning.  By  my  gastrograph  it  was  found  that  the  rate  of  peristalsis  was  now 
unmistakably  impeded,  though  there  was  no  evident  dilation. 

The  results  of  the  analysis  of  the  gastric  contents  were  now  as  follows  :  Free 
HCl,  6;  combined  HCl,  4;  lactic  acid,  a  trace  ;  total  acidity,  18  ;  biuret  reac- 
tion positive,  erythrodextrin,  o.  The  patient  was  allowed  to  take  only  a 
liquid  diet.  Nevertheless,  120  c.c.  of  offensive  stomach-contents  could  be 
drawn  away  every  morning  before  breakfast,  which  contained  no  free,  but 
only  combined,  HCl,  and  lactic  acid.  Microscopically,  large  numbers  of 
bacteria  in  threads  were  found,  yeast  in  moderate  amounts,  no  sarcinae,  but 
many  cylindrical  and  cuboidal  epithelial  cells.  The  urine  contained  no 
sugar  nor  albumin ;  the  amount  in  twenty-four  hours  was  about  one  liter. 
Indican  was  present,  but  not  in  excess.  Once  daily  the  patient  suffers  from 
severe  cramp-like  pains  in  the  region  of  the  stomach,  but  these  attacks  were 
not  associated  with  vomiting.  After  the  patient  had  mastered  the  technic 
of  lavage  he  improved  very  much,  and  gained  eighteen  pounds  in  weight  in 
eight  months.  In  October,  1895,  he  returned  again  for  medical  treatment 
because  he  began  to  have  vomiting  attacks  again,  although  he  had  been  ex- 
ceedingly careful  in  his  diet.  He  now  had  very  aggravated  motor  insuffi- 
ciency, so  that  we  once  more  attempted  to  dilate  his  pylorus  by  intubation. 
The  lavage  and  liquid  diet  were  continued.  There  were  evidences  of  very 
severe  chronic  gastritis,  as  shown  in  a  fragment  of  mucosa  brought  out  during 
lavage  by  the  patient.  As  HCl  was  absent  on  repeated  examination,  both  in 
the  free  and  combined  form,  the  ferments  were  very  much  reduced.  Rennin 
zymogen,  active  in  dilution  i  :  30 ;  discs  of  serum  albumin  placed  in  the 
filtrates,  acidified  with  HCl,  required  four  hours  for  digestion.  Lactic  acid  present 
to  such  an  amount  as  to  give  very  distinct  reaction  with  Uffelmann's  test. 

Examination  of  the  Abdomen. — The  stomach  was  so  distended  that  its  con- 
tours were  very  distinctly  visible  without  artificial  distention.  No  tumor  could 
be  palpated.  Liver  normal  on  percussion  and  palpation.  Spleen  and  kidneys 
normal.     Distention  of  the  colon  with  COj  showed  it  in  normal  position. 


EXAMINATION    OF   THE    ABDOMEN.  617 

By  electrodiaphany  the  stomach  was  found  to  be  not  enlarged,  though  the 
lower  curvature  was  distended  to  within  one  inch  of  the  navel.  By  the  use  of 
liquid  diet  and  daily  lavage,  together  with  intubation  of  the  pylorus,  the  patient 
improved  once  more.  As  the  diagnosis  of  the  hypertrophic  stenosis  of  the 
pylorus  was  now  clear,  the  patient  was  once  more  urgently  advised  to  undergo 
an  operation.  This  he  refused  emphatically.  After  he  left  my  supervision  I 
did  not  see  him  again  until  June,  1896.  He  was  so  much  emaciated  that 
I  failed  to  recognize  him.  He  appeared  like  a  patient  in  the  last  stagesof  pul- 
monary tuberculosis.  The  stomach  was  not  very  much  dilated,  but  filled  with 
putrescent  material,  and  had  descended  lower  than  at  the  last  examination. 
Notwithstanding  artificial  feeding  with  enemata,  the  patient  died  within  ten 
days  after  this  visit. 

At  the  autopsy  I  found  the  pylorus  very  much  thickened — its  walls  in  one 
place  measuring  three  centimeters  in  thickness.  The  muscular  layer  showed 
the  greatest  increase  in  thickness.  The  mucous  layer  was  lost  entirely  over 
this  region.  The  thickening  extended  throughout  the  entire  pyloric  region  of 
the  stomach.  The  atrophy  of  the  glandular  layer  extended  all  over  the  surface 
of  the  stomach.  In  the  middle  portion  of  the  stomach,  on  the  greater  curva- 
ture, there  was  a  small  polypus  about  the  size  of  a  lentil.  The  passage  through 
the  pylorus  was  tortuous,  so  that  not  even  a  straight  needle  two  millimeters  in 
thickness  could  be  made  to  pass.  There  was  no  histological  evidences  of  car- 
cinoma. In  plate  XI  the  histological  features  of  chronic  hyperplastic  gastritis 
with  pyloric  stenosis  are  successfully  reproduced.  The  enormous  hyperplasia 
of  the  muscularis  and  the  connective  tissue,  and  the  hypertrophy  of  the  pylorus 
are  especially  clear. 

Age. — Pyloric  hypertrophy  in  the  sequence  of  hypertrophic  gastri- 
tis is  a  disease  occurring  at  a  comparatively  young  age:  thus  the 
cases  of  Einhorn  (/.  c),  in  which  the  ages  are  stated,  show  the  follow- 
ing. Some  of  these  cases  were  not  due  to  stenosing  gastritis  but  to 
other  causes,  probably  cicatrices : 

Einhorn's  Cases.  Number  of  Cases.  Age. 

Males, 4  28,  34,  40,  48  years. 

Females,  3  38,  43,  58 

Boas'  Cases.  Number  of  Cases.  Age. 

Males, 2  32,  47  years. 

Females, i  43      " 

Hemmeter's  Cases.  Number  of  Cases.  Age. 

Males, 2  23,  38  years. 

Females, 2  28,  36     " 

Tilger  (/.  c.)  reported  23  cases,  as  follows: 

4  cases  at  the  age  of  from  20  to  30  years. 
7      •*  "  "         "     301040      " 

b     "  "         "        "     40  to  50 

2     "  "         "        "     50  to  60      " 

2     "  "         *'         "     60  to  70      " 

2  cases  over  70  )ears. 


6l8  HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS. 

If  it  were  known  how  long  these  cases  had  been  suffering  before 
they  came  to  the  physician,  a  more  uniform  age  could  be  arrived  at. 
Thus,  one  of  Hinhorn's  cases  suffered  from  digestive  troubles  for 
twenty  years,  another  for  eight,  another  for  eighteen,  another  for 
fourteen.  One  of  Boas'  cases  had  suffered  for  nineteen  years,  a 
second  six,  and  a  third  two  and  a  half  years.  In  my  own  cases  the 
one  that  came  to  me  at  the  age  of  thirty-eight  had  been  suffering  for 
four  3^ears ;  and  the  female  patient  who  consulted  me  at  the  age  of 
thirty-six  had  suffered  for  three  3^ears.  Deducting  the  time  of  the 
suffering  already  experienced  from  the  age  of  the  patient  when  pre- 
sented for  diagnosis,  it  is  evident  that  a  comparatively  early  period 
of  life  will  be  found  to  haA"e  been  the  stage  at  which  these  total  25 
cases  were  first  affected.  From  these  figures  another  important 
moment  in  the  diagnosis  is  evident — viz.,  the  chronicity  of  the 
process. 

Symptomatology. — When  the  cases  first  present  themselves,  the 
first  symptoms  have  existed  for  a  long  time.  The  anamnesis  re- 
sembles the  beginning  of  chronic  gastritis.  The  complaints  are  full- 
ness, pressure,  distention,  pain,  eructation,  and,  occasionally,  pyrosis. 
As  the  stenosing  gastritis  progresses,  motor  insufficiency  of  the  first 
degree  develops ;  and  then  the  principal  symptoms  are  vomiting  and 
pain.  Gradually  the  classical  signs  of  dilation  of  the  stomach  may 
develop;  but  not  in  all  cases  where  we  have  these  symptoms  is  the 
stomach  dilated.  Owing  to  the  obstruction  there  are  loss  of  weight, 
constipation,  and  reduction  in  the  amount  of  urine.  The  appetite  re- 
mains good,  or  it  is,  at  least,  good  in  the  majority  of  cases  for  a  long 
time. 

Size  of  the  Stomach. — In  the  three  cases  we  obsen."ed  the  size  of  the 
stomach  was  not  markedly  increased,  and  in  the  second  male,  aged 
twenty-three  years,  the  stomach  at  the  autopsy  held  only  one  ounce. 
This  stomach  in  its  actual  size  is  represented  in  plate  XII ;  in  another 
case  there  was  an  undoubted  gastroptosis.  In  only  one  of  the  cases, 
which  Einhorn  describes  in  detail,  was  the  stomach  dilated.  In  the 
other  three  it  appears  that  this  condition  was  not  especially  investi- 
gated. Boas  describes  dilation  in  but  one  of  his  three  cases.  Hem- 
atemesis  has  not  been  observed  in  connection  with  this  disease  by 
Boas,  Lebert,  Einhorn,  or  the  author.  If  the  hyperplasia  has  in- 
volved only  the  pylorus,  a  dilation  is  likely  to  result;  but  if  it  has 
extended  uniformly  throughout  the  organ  (linitis  plastica),  a  cirrhotic 
contraction  ensues. 


PLATE  XI. 


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SYMPTOMATOLOGY   OF   STENOSING   GASTRITIS.  619 

Tumor. — Einhorn  found  a  palpable  tumor  in  only  one  of  his  cases, 
and,  similarly,  Boas  reports  the  existence  of  tumor  in  one  out  of  his 
three  cases.  In  the  case  described  in  this  account,  although  the 
pyloric  mass  was  as  large  as  a  hen's  egg  at  the  autopsy,  it  had  not  been 
detected  before  death  because  the  pylorus  was  in  the  normal  position 
— under  the  right  lobe  of  the  liver. 

Condition  of  the  Gastric  Secretions. — The  state  of  the  secretion  of  the 
gastric  juice  will  vary  according  to  the  duration  of  the  disease  and  the 
period  at  which  the  patient  presents  himself.  It  is  rational  to  pre- 
sume that  if  the  stenosis  is  brought  on  by  a  chronic  gastritis,  the 
longer  the  disease  has  existed  the  more  atrophic  will  the  mucosa  have 
become  and  the  less  gastric  juice  will  be  secreted.  Nevertheless, 
Einhorn  found  free  HCl  in  one  of  his  cases  that  had  suffered  for  eight 
years  prior  to  consulting  him.  In  all,  Einhorn  gives  an  account  of  ten 
cases  ("New  York  Medical  Record,"  January,  1895),  but  only  four  of 
them  are  described  in  detail ;  not  all  of  these  cases,  it  seems,  were  due 
to  hyperplastic  gastritis.  They  all  showed  retention  of  food,  considera- 
ble quantities  of  gastric  juice,  presence  of  free  HCl,  absence  of  lactic 
acid,  a  high  total  acidity,  and  a  long  duration  of  sickness.  Only  in 
one  of  these  cases  did  he  find  absence  of  free  HCl  and  presence  of  lactic 
acid.  In  the  three  cases  reported  by  Boas  free  HCl  was  regularly 
absent,  and  in  two  cases,  in  addition  to  absence  of  free  HCl,  the  fer- 
ments were  very  much  reduced.  All  three  had  an  unmistakable 
lactic  acid  reaction.  In  my  cases  free  HCl  was  present  at  the  begin- 
ning, but  as  the  disease  progressed,  it  gradually  became  less  and  less, 
and  finally  both  free  and  combined  HCl  was  absent;  then  the  reac- 
tion for  lactic  acid  became  positive. 

Boas  considers  the  absence  of  free  HCl  and  ferments  an  important 
factor  in  the  diagnosis  of  hypertrophic  stenosis  caused  by  gastritis. 
This  was  the  condition  in  two  of  my  cases.  It  is  evident  from  the 
autopsy  report  of  one  of  my  cases  that  it  was  undoubtedly  due  to 
stenosing  gastritis ;  free  HCl  was  absent,  but  the  ferments  active  at  a 
time  when  the  diagnosis  of  hypertrophic  pyloric  stenosis  could  be 
made  beyond  a  doubt. 

Diagnosis. — At  the  time  when  the  patient  first  presents  himself, 
the  differential  diagnosis  between  benign  stenosing  gastritis  and  car- 
cinoma presents  difficulties ;  but  if  we  can  clearl}^  ascertain  a  history 
of  many  years  of  suffering,  with  alternating  improvements  and  aggra- 
vations of  the  symptoms,  and  the  increase  and  decrease  of  body 
weight,  the  improvement  on  carefully  selected  liquid  diet  and  aggra- 
41 


620  HYPERTROPHIC   STENOSIS   OF   THE  PYLORUS. 

vation  on  a  solid  diet,  we  should  be  justified  in  suspecting  a  slowly 
developing  benign  process.  Rosenheim  (/.  c.)  has  reported  a  case  of 
benign  stenosis*  in  which  the  presence  of  a  tumor  was  recognized,  and 
the  same  gastric  chemistry  as  in  carcinoma,  with  the  same  pernicious 
tendency.  A  differential  diagnosis  between  such  a  case  as  this  and 
carcinoma  seems  impossible. 

It  may  become  necessary  to  distinguish  between  stenosis  caused 
by  gastritis  and  that  caused  by  cicatricial  contraction  of  the  pylorus 
resulting  from  a  gastric  ulcer,  and  also  from  the  dilation  and  food 
retention  from  primary  and  atonic  gastrectasia.  In  the  stenosis  re- 
sulting from  gastritis  there  will  have  been  no  preceding  gastric  nor 
intestinal  hemorrhages,  which  will  in  most  cases  have  occurred  in  case 
there  is  a  cicatrix  from  an  ulcer.  If  the  stenosis  is  due  to  gastritis, 
free  HCl  will  eventually  be  absent.  The  fact  that  Einhorn  found  free 
HCl  in  so  many  of  his  cases  makes  it  probable  that  the  constriction  of 
the  pylorus  was  not  due  to  stenosing  gastritis,  but  to  some  other 
cause — cicatrices,  for  instance.  A  histological  examination  of  the 
pyloric  tissue  does  not  seem  to  have  been  made  in  his  cases.  From 
primary  atonic  dilation  stenosing  gastritis  can  be  differentiated  by  the 
absence  of  the  symptoms  of  gastritis  in  the  former.  Visible  spas- 
modic peristalsis  indicates  stenosing  gastritis. 

The  previous  history  of  the  case  with  its  peculiar  variations  will  be 
extremely  important.  Marked  and  lasting  improvements,  with  in- 
crement of  weight,  do  not  occur  in  carcinoma.  The  periods  of  im- 
provements in  this  latter  disease,  if  they  occur  at  all,  do  not  exceed 
one  month.  In  benign  hypertrophic  stenosis  the  symptoms  of  stag- 
nation are  more  amenable  to  treatment  than  in  carcinoma.  The 
disturbances  of  the  motor  function  in  the  latter  disease  increase  pro- 
gressively, and  the  quantity  of  food  remnants  retained  and  found  in 
the  stomach  before  breakfast  becomes  more  and  more  from  week  to 
week,  no  matter  upon  what  diet  the  patient  is  placed.  In  hyper- 
trophic stenosis  the  symptoms  of  stagnation  may  disappear  for  years 
under  the  aid  of  a  liquid  diet  and  lavage.  Only  in  the  ver}^  last  stages 
of  the  disease  does  the  stagnation  become  absolute.  Whenever  there 
are  glandular  swellings,  coffee-ground  vomiting,  ascites,  or  evidences 

*  A  similar  case  originally  reported  by  Dr.  W.  S.  Thayer  is  often  quoted  in  text-books 
as  having  shown  the  same  gastric  chemistry  as  carcinoma  and  yet  proved  to  be  a  benign 
tumor.  Dr.  Thayer  has  informed  me  privately  that  the  detection  of  lactic  acid  in  this 
case  was  due  to  an  error  in  the  preparation  of  the  patient's  stomach  before  the  test-meal 
was  drawn  for  analysis. 


PLATE  XI 


PROGNOSIS   O'P   STENOSING   GASTRITIS.  62 1 

of  metastases,  presence  of  Oppler-Boas  bacilli  in  the  stomach-con- 
tents, the  case  will  have  to  be  considered  carcinoma.  The  tendency 
is  toward  early  diagnosis  and  early  operation  in  both  conditions. 
From  this  standpoint,  a  possible  error  in  differentiating  the  two  condi- 
tions will  not  be  a  serious  one. 

The  presence  or  absence  of  tumor  in  the  region  of  the  pylorus  is  of 
no  diagnostic  value  in  the  differentiation  in  benign  stenosis  and  car- 
cinoma. If  a  tumor  is  present,  it  may  as  readily  be  a  benign  hyper- 
trophy as  a  cancer ;  and  if  it  is  absent,  it  does  not  exclude  the  diagnosis 
of  either  of  these  conditions.  It  is  of  greatest  importance  in  such 
cases,  when  the  diagnosis  lies  between  these  two  conditions,  to  take 
the  weight  of  the  patient  frequently  and  analyze  the  gastric  contents 
repeatedly.  In  a  case  which  we  had  examined  since  June,  1892,  and 
who  died  in  June,  1 896,  free  HCl  was  present  ten  months  before  the 
fatal  termination;  but  after  that,  an  examination  made  eight  months 
before  the  end,  showed  no  free  HCl  and  excess  of  lactic  acid. 

Prognosis. — The  disease  is  fatal  unless  an  operation  is  undertaken 
in  time.  The  remarkable  variations  in  improvement  and  aggrava- 
tion are  apt  to  mislead  the  clinician  into  a  favorable  prognosis.  In 
order  to  form  an  approximate  idea  of  the  gravity  of  the  case,  it  is 
necessary  to  test  the  motor  function.  We  give  preference  to  Hem- 
meter's  method  by  means  of  the  intragastric  rubber  bag,  and  a  small 
water  manometer ;  because  after  trying  the  other  methods  for  testing 
the  motility  we  have  found  that  they  failed  to  give  accurate  results. 
There  are  three  means  by  which  we  may  gage  the  state  of  the  motor 
functions  clinically:  (i)  The  amount  of  stagnating  stomach-contents 
gained  by  the  expression  method,  without  addition  of  water,  from  the 
fasting  stomach;  (2)  repeated  consecutive  weighings  of  the  body;  (3) 
repeated  and  consecutive  measurements  of  the  urine  passed  in  twenty- 
four  hours.  During  the  beginning  stages  of  the  process,  and  as  the 
stenosis  is  not  very  much  advanced,  it  will  be  possible  to  introduce 
the  amount  of  calories  necessary  to  maintain  the  nitrogen  balance  by 
giving  a  liquid  diet,  consisting  of  milk,  soft-boiled  eggs,  and  predi- 
gested  foods.  When  the  gastritis  has  advanced,  there  is  no  secretion 
of  HCl  and  ferments,  and  therefore  there  can  be  no  gastric  digestion 
of  the  food  whatever,  and  it  is  offered  to  the  pylorus  in  a  much  coarser 
state  than  if  the  secretions  were  normal. 

Treatment. — This  may  be  palliative  or  curative.  The  palliative 
treatment  consists  in  avoiding  everything  that  might  increase  the 
gastritis.     Alcohol,  tobacco,  irritating  condiments,  and  spices  must 


62  2  HYPERTROPHIC    STENOSIS    OF    THE    PYLORUS. 

be  excluded.  The  diet  had  best  consist  of  milk  and  soft-boiled  or 
raw  eggs ;  the  latter  only  as  long  as  free  HCl  is  present  in  the  stomach. 
After  the  gastric  stagnation  has  advanced,  and  offensive  residues  are 
found  in  the  stomach  eA'er\'  morning,  laA'age  is  the  treatment  indi- 
cated. It  is  best  carried  out  with  water  acidulated  with  dilute  HCl, 
or  with  water  containing  one  teaspoonful  of  table  salt  to  the  quart. 
Rectal  alimentation  is  indicated  in  advanced  emaciation  from  abso- 
lute pyloric  stenosis,  whenever  immediate  operation  is  not  feasible. 

Medicinal  Treatment. — This,  in  our  experience,  is  of  little  or  no 
utilit}',  though  according  to  the  chemical  nature  of  the  case  HCl, 
pancreatin,  and  papain  may  be  employed. 

Duodenal  Intubation. — A  method  by  which  a  tube  can  be  passed 
through  the  stomach  and  pylorus  into  the  duodenum  is  original  with 
the  author,  and  was  first  employed  at  his  clinic  ("Arch.  f.  Verdau- 
ungskr.,"  Bd.  ii,  S.  85).  I  have  carried  out  this  method  in  a  case  of 
hypertrophic  stenosis,  but  it  was  followed  by  partial  success  only. 
Although  I  succeeded  in  dilating  the  stricture  of  the  pylorus  for  a 
time,  the  disease  that  caused  it  could  not  be  cured  thereby,  and  sooner 
or  later  the  stenosis  resumed  its  former  degree.  The  only  method  to 
cure  the  patient  is  by  operation. 

Operation. — Every  influence  should  be  brought  to  bear  upon  the 
patient  to  obtain  the  consent  for  an  early  operation.  If  the  stenosis 
is  absolute,  and  food  no  longer  passes  the  pylorus,  the  operation  should 
not  be  postponed  a  single  day.  The  types  of  operation  that  are 
available  are  gastro- enterostomy  and  the  pyloroplastic  operation  of 
von  Heineke-]\Iikulicz.  The  so-called  pyloroplastic  operation  or 
digital  divulsion  of  Loreta  does  not  compare  favorably  in  its  results 
to  the  operative  methods  just  mentioned. 

Postoperative  Treatment. — After  the  stenosis  has-been  cured,  the 
still-existing  gastritis  will  require  further  dietetic,  mechanical,  and 
medicinal  treatment,  according  to  the  principles  laid  down  in  the 
section  on  Chronic  Gastritis. 


LITERATURE    ON    THE    HYPERTROPHIC    STENOSIS    OF    THE 

PYLORUS. 

1.  Boas,  I.,  "  Ueber  hypertrophische  Pylorusstenose,"  etc.,  "  Archiv  f.  Ver- 
dauungskrankh.,"  Bd.  IV,  S.  41. 

2.  Codivilla,  "  Gazeta  degli  ospitali  die  Milano,"  188S. 

3.  Dubujadoux,  "  Sur  une  variete  de  cirrhose  encore  inedite  accompagnant 
la  gastrite  chronique  avec  sclerose  sous  muqueuse  hypertrophique,"  "  Gaz. 
hebd.,"  1883. 


LITERATURE   ON   HYPERTROPHIC   STENOSIS   OF   PYLORUS.        623 

4.  Einhorn,  "  New  York  Med.  Jour.,"  January,  1895  ;  see  also  "  Diseases  of 
the  Stomach,"  by  same  author. 

5.  Finkelstein,  H.,  "Ueber  angeborene  Pylorusstenose,"  "  Jahrb.  f.  Kinder- 
heilkunde,"  Bd.  XLiii,  S.  i,  1896. 

6.  Gran,  Chr.,  "  Bemerkungen  uber  die  Magenfunktionen  u.  die  anatom- 
ischen  Veranderungen  bei  angeborener  Pylorusstenose,"  ibid. 

7.  Hammerschlag,  "  Boas'  Archiv  f.  Verdauungskrankh.,"  Bd.  11,  S.  19. 

8.  Hanot  et  Gombault,  "  Archives  de  Physiologic  normale  et  Pathologique," 
Bd.  IX,  p.  412,  1882. 

9.  Hemmeter,  John  C,  and  Wm.  R.  Stokes,  "  Hypertrophic  Gastritis  and 
Pyloric  Stenosis  "  ;  Memorial  Vol.  in  honor  of  25th  Anniversary  of  Doctorate 
of  Prof.  Wm.  H.  Welch,  Johns  Hopkins  University  (Feb.,  1900). 

10.  Hirsch,  "  Freie  Vereinigung  der  Chirurgen,"  22.  Juni,  1896. 

11.  Von  Kahlden,  "Centralbl.  f.  khn.  Med.,"  1887. 

12.  Lebert,  "  Die  Krankheiten  des  Magens,"  Tubingen,  1878,  S.  525. 

13.  Nauwerck,  "  Deutsches  Arch.  f.  klin.  Med.,"  1878,  Bd.  xxi,  S.  574. 

14.  Rosenheim,  "  Berl.  klin.  Wochenschrift,"  1894,  No.  39. 

15.  Schoch,  Inaug. -Dissert.,  Zurich,  1857. 

16.  Thayer,  W.  S.,  "Johns  Hopkins  Hospital  Report,"  1893,  No.  31. 

17.  Tilger,  "Ueber  die  stenosierende  Pylorushypertrophie,"  "  Virchow's 
Arch.,"  Bd.  cxxxii,  H.  2,  S.  290. 


CHAPTER   VII. 
MOTOR  INSUFFICIENCY. 


Gastric  Atony  or  Myasthenia. — Gastrectasis   {Dilation  of  the 
Stomach). — Obstruction  of  the  Orifices. 

There  is  no  uniformity  in  the  classification  of  the  various  forms  and 
degrees  of  abnormal  enlargement  of  the  stomach. 

The  defective  function  in  these  cases  is  not  commensurate  with  the 
size  and  capacity,  but  with  the  tonicity  of  the  peristalsis.  A  very 
large  stomach  (megalogastria)  may  have  a  perfect  motor  function, 
and  a  very  small  stomach  may  have  a  defective  motility. 

Boas  recognizes  a  mechanical  insufficiency  of  the  first  degree,  which 
is  a  myasthenia  or  atony  of  the  gastric  muscularis  in  which  the  in- 
gesta  remain  in  the  stomach  too  long,  but  finally  are  completely 
moved  out  into  the  intestines.  There  is  no  absolute  retention  of 
food,  but  simply  a  delay  in  the  expulsion.  Boas  calls  the  fully  de- 
veloped dilation  mechanical  insufficiency  of  the  second  degree. 


624  MOTOR    INSUFFICIENCY. 

Riegel  differentiates: 

1.  Simple  atony,  or  insufficiency  of  the  stomach. 

2.  Atonic  or  typical  ectasia,  or  dilation. 

3.  Secondary  ectasia,  or  pyloric  stenosis  with  ectasia  {dilation). 
Naunyn  speaks  simply  of  motor  insufficiency,  and  Rosenbach  of 

mechanical  gastric  insufficienc5^  Schreiber  (Boas,  "Archiv  f.  Ver- 
dauungskrankheiten,"  Bd.  11,  S.  423),  in  attempting  to  select  a  desig- 
nation which  should  signify  the  most  constantly  present  condition  of 
all  these  morbid  states  of  motility,  and  one  which  should  unite  them 
all  around  itself,  reached  and  suggested  the  term  stasis  stomach 
("Stauungsmagen"),  with  permanent  digestion  or  "permanently 
digesting  stomach."  Besides  being  a  cumbersome  circumlocution, 
the  term  does  not  even  include  all  conditions  of  this  type,  for  in  Boas' 
mechanical  insufficiency  of  the  first  degree  and  in  Riegel's  simple 
atony— conditions  which  we  are  convinced  really  do  exist — there 
is  certainly  no  permanent  digestion. 

Permanent  digestion  goes  on  in  fully  developed  dilations  with  im- 
paired peristalsis  as  long  as  h^^drochloric  acid  and  ferments  are 
secreted.  But  as  there  undoubtedly  are  long-standing  dilations  with 
achylia  gastrica,  or  loss  of  secretion  (Kinhom),  there  can  be  no  diges- 
tion in  them.  The  fact  that  the  food  is  overretained  in  them  does  not 
imply  that  it  is  digested;  only  in  dilations  that  show  hydrochloric 
acid  and  ferments  can  we  speak  of  permanent  digestion.  The  efforts 
of  Schreiber  to  establish  Reichmann's  chronic  secretion  as  a  complica- 
tion of  dilation  with  retained  food  products  and  permanent  secretion 
caused  by  stimulation  of  the  retained  food,  are  verv^  convincing. 
We  shall  speak  of  the  pathogenesis  of  gastrosuccorrhea,  or  Reich- 
mann's disease,  under  the  Nervous  Affections  of  the  Stomach.  It  is 
impossible,  however,  to  invent  a  term  which  shall  comprise  the  im- 
portant features  of  all  types  of  motor  and  mechanical  insufficiency, 
and  probably  as  clear  a  classification  as  any  is  one  based  on  Riegel 
and  Boas,  as  follows : 

1.  Simple  gastric  atony  or  motor  insufficiency  or  myasthenia 
without  dilation. 

2.  Atonic  dilation  (motor  insufficiency  due  to  relaxation  of  the 
gastric  walls)  without  pyloric  stenosis. 

3.  Secondary  dilation  (motor  insufficiency  due  to  pyloric  stenosis). 
The  one  common  sign  is  not  the  retention  of  food  nor  permanent 

digestion,  but  the  impaired  motility. 

Etiology. — Two  kinds  of  cases  may  occur:  either  the  atony  of  the 


CLASSIFICATION    OF    MOTOR   INSUFFICIENCY.  625 

gastric  wall  is  not  due  to  a  mechanical  obstacle, — in  this  case  nothing 
will  oppose  the  free  course  of  the  contents,  and  they  will  only  linger 
in  the  stomach  because  the  latter  is  really  incapable  of  ejecting  them 
from  its  cavity  in  proper  time, — or  the  atony  will  be  due  to  a  pyloric 
stenosis;  the  muscular  tonicity  will  have  been  overcome  by  an  im- 
passable obstacle,  the  fibers  exhaust  themselves  in  contending  with 
an  excessive  resistance,  and  the  dilation  may  then  be  considered  as 
following  on  existence  of  the  obstacle.  In  the  first  case  the  etiology- 
is  variable,  and  arises,  finally,  from  a  defect  in  the  nutrition  of  the 
muscular  layer  or  in  the  innervation;  in  the  other  case  it  is  purely 
mechanical. 

DILATION  CAUSED  BY  A  MECHANICAL  OBSTACLE. 

Intrinsic  causes  of  opposition  to  the  passage  of  stomach-contents 
into  the  intestines,  and  of  such  a  resistance  to  the  contractions  of  the 
stomach  that  it  dilates,  are,  first  of  all,  the  constrictions  of  the  pylo- 
rus. These  are  generally  the  result  of  anatomical  alterations — viz., 
cancer,  cicatrices,  circular  ulcer,  or  muscular  hypertrophy  of  the 
pyloric  sphincter. 

Nauwerk  (/.  c.)  was  one  of  the  first  to  draw  attention  to  hyperplasia 
and  hypertrophy  of  the  pyloric  sphincter  as  a  cause  of  dilatation 
(which  has  been  considered  in  a  special  chapter).  A  spasm  of  the 
pylorus,  which  can  be  compared  to  a  spasm  of  the  sphincter  of  the 
anus,  can  constitute  an  obstruction  equally  well.  This  spasm,  which 
has  been  admitted  by  authors  for  a  long  time, — for  reasons  a  little 
theoretical  perhaps, — has  been  demonstrated  since  gastric  surgery 
has  permitted  a  more  direct  exploration.  Martin  (/.  c.)  has  reported 
a  case  in  which  a  pylorus  large  enough  to  admit  the  passage  of  two 
fingers  brought  on  a  considerable  dilation  by  its  spasmodic  constric- 
tion, consequent  upon  a  circular  ulcer  accompanied  by  considerable 
hyperacidity.  Landerer  (/.  c.)  is  said  to  have  proved  the  existence  of 
a  congenital  pyloric  constriction  analogous  to  the  congenital  mitral 
constriction  described  by  some  authors.  He  collected  ten  such  ob- 
servations, and  claimed  that  this  orifice,  though  large  enough  during 
infancy,  might  undergo  an  arrest  of  development  and  remain  very 
small,  while  the  stomach  grows  larger  with  age;  a  serious  dilation 
would  result  from  these  diverging  effects.  (See  Congenital  vStenosis 
of  Pylorus.) 

However,  the  obstacle  does  not  necessarily  have  its  seat  in  the 
tissue  of  the  pylorus  itself.     In  the  chapter  on  Benign  Tumors  we 


62  6  MOTOR   IXSUFFICIEXCY. 

have  described  the  possibility  of  a  polypus  growing  from  the  mucosa 
some  distance  from  the  pylorus  and  by  means  of  a  long  pedicle  capable 
of  bringing  about  a  dilation  by  becoming  fixed,  more  or  less,  in  the 
intestinal  orifice,  and  thus  causing  its  occlusion,  acting  like  a  baU- 
valve.  Deiters  (/.  c.)  has  collected*  a  large  number  of  obser\^ations, 
in  which  congenital  malformations,  abnormal  foldings,  diverticula, 
and  atresia  had  provoked  dilations  by  constricting  the  intestine  in 
the  immediate  vicinity  of  the  pylorus.  An  anatomical  lesion  of  the 
duodenum — the  cicatrix  of  an  ulcer,  for  example — would  produce 
the  same  effects  by  diminishing  the  caliber  of  the  passage. 

The  causes  of  extrinsic  origin  which  haA"e  been  observ^ed  to  efifect 
compression  of  the  pylorus  or  duodenum  are  very  numerous.  Among 
these  are  peritoneal  adhesions,  circumscribed  or  not,  the  results  of 
former  inflammations.  Fibrous  bands  issuing  from  a  gastric  cicatrix 
ma}*  so  distort  the  normal  location  of  the  pylorus  (although  not 
situated  in  the  pylorus  itself)  as  to  compel  the  duodenum  to  de- 
scribe an  abnormal  course. 

Inflammations  originating  in  the  liver  and  the  pancreas  may  be 
the  starting-point  of  similar  anatomical  modifications.  The  head 
of  the  pancreas,  so  intimately  connected  with  the  duodenum,  may 
become  cystic  or  cancerous,  and  cause  a  duodenal  stenosis  by  com- 
pression, with  following  dilation  of  the  stomach.  A  congenital 
displacement  of  the  duodenum  would  bring  about  the  same  disorders 
(Cechini).  Biliary  concretions,  by  dilating  the  diverticulum  of 
Vater,  or  by  compressing  the  intestinal  wall,  may  produce  a  com- 
pression of  the  duodenum  sufiicient  to  bring  about  gastric  dilation; 
Grundzach  has  recently  reported  a  case  of  this  kind.  Landau  (I.  c), 
Bartels  (/.  c),  A^'arnek  (/.  c),  ]\Iueller  (/.  c),  Litten  (/.  c),  and  other 
authors  have  studied  the  relations  of  dislocation  of  the  right  kidney 
to  gastric  dilation.  Similar  studies  have  been  made  in  an  inter- 
esting work  by  Bruhl,  and  Mathieu  has  also  recently  reported  new 
cases  (Societe  Medicale  d'Hopitaux).  Patients  presenting  this 
coincidence  of  movable  kidney  and  dilation  of  the  stomach  are  usu- 
ally young  girls  or  women  of  the  working  class,  who  are  in  the  habit 
of  fixing  their  skirts  above  their  hips,  or  lacing  tightly,  causing  an 
external  constriction,  which  is  shown  by  the  presence  of  a  permanent 
furrow.  We  append  two  illustrations  showing  the  effect  of  tight 
lacing  in  producing  distortions  and  dislocation  of  the  stomach. 

*  From  the  Anatomical  Pathological  Institute  of  Greifswald. 


ETIOLOGY    OF    DILATIONS.  627 

Figure  40  illustrates  the  female  skeleton  and  the  funnel  shape 
given  to  the  lower  thorax  by  lacing — the  stomach  being  pressed 
down  into  approximately  the  position  indicated  by  the  dotted  out- 
line, the  antrum  pylori  coming  immediately  beneath  the  umbilicus. 
The  stomach  is  not  pressed  upon  directly,  but  is  displaced  by  the 


Fig.  40. — Diagrammatic  Illustration  of  the  Mechanism  Effecting  Vertical  Position 

OF  THE  Stomach. 

Compression   of  thorax  by   lacing,  producing;  a   funnel    shape,   forcing   liver   down    upon    the 

stomach.     Antrum  of  pylorus  (A)  descends  below  umbilicus  (U). 


pressure  of  the  liver.     This  vertical  position  can  also  be   brought 
about  by  the  weight  and  dragging  of  neoplasms. 

A  second  malformation  of  the  gastric  cavity  is  the  looped  or  twisted 
stomach,  caused  by  lacing  and  probably  by  cicatricial  contractions 
along  the  lesser  curvature.  The  loop  form  is  brought  about  by  closer 
and  closer  approximation  of  cardia  and  pylorus  (Plate  XIII).  Dila- 
tion is  easily  developed  from  the  vertical  position,  because  overre- 
tained  ingesta  dilate  at  first  the  antrum  and  later  the  entire  gastric 


62  8  MOTOR   INSUFFICIENCY. 

cavity.  The  vertical  part  of  the  duodenum,  it  must  be  remembered, 
is  firmly  adherent  to  the  spinal  column  and  can  not  descend ;  if,  there- 
fore, the  antrum  or  the  pylorus  lies  lower, — as,  for  instance,  in  the 
loop  form  and  vertical  position, — the  evacuation  is  much  more  diffi- 
cult than  in  the  normal  stomach  position,  because  the  ingesta  must  be 
lifted  up  to  the  pylorus.  Only  in  the  recumbent  position  and  when 
the  patient  lies  on  the  left  side  can  the  organ  be  evacuated.  The 
musculature  of  such  distorted  and  dislocated  stomachs  is  called  upon 
to  make  excessive  and  superfluous  expulsive  efforts,  whereby  it 
readily  becomes  exhausted.  The  time  of  gastric  digestion  conse- 
quently becomes  prolonged,  and  the  gastric  wall  is  overdistended  and 
a  motor  insufficiency  is  gradually  established.  Kussmaul  first  called 
attention  to  kinking  of  the  duodenum,  occurring  at  the  juncture  of  the 
movable  horizontal  and  the  fixed  vertical  portion  of  duodenum,  and 
caused  by  the  dragging  of  dilated  or  distorted  stomachs.  This  con- 
stitutes an  additional  mechanical  obstruction,  and  has  been  observed 
by  the  author  during  a  laparotomy — the  horizontal  part  of  the  duo- 
denum was  kinked  off  and  the  first  part  following  the  pylorus  was 
dilated.  H.  W.  Bettman  has  presented  some  instructive  diagram- 
matic representations  of  the  descent  of  the  stomach  and  the  forma- 
tion of  subpyloric  (antral)  pouch  ("Philadelphia  Monthly  Medical 
Journal,"  vol.  i,  p.  144). 

Men  who  wear  a  belt  or  strap  may  produce  the  same  results.  Lud.. 
Knapp  ("Wanderniere  bei  Frauen,"  Berlin,  1896)  associates  the 
frequency  of  floating  kidney  with  abnormalities  in  the  pelvic  organs 
in  women,  causing  constant  dragging  on  the  kidneys  by  means  of  the 
ureters.  The  right  kidney  may  become  displaced  forward  and  in- 
ward, pressing  upon  the  fixed,  descending  portion  of  the  duodenum, 
which  is  situated  between  the  hilum  of  the  kidney  and  the  vertebral 
column.  Such  partial  obliteration  of  the  intestine  would  bring  about 
a  slower  and  more  difficult  evacuation  of  the  contents  of  the  stomach ; 
but  this  is  conceivable  only  if  the  dislocated  kidney  has  become  fixed 
in  its  abnormal  position.  We  shall  treat  the  effects  of  floating  kid- 
ney more  fully  in  the  chapter  on  Enteroptosis. 

Ewald  (/.  c.)  and  Pertick  (/.  c.)  have  gathered  together  a  certain 
number  of  cases  in  which  a  hernia  of  the  floating  portion  of  the  duo- 
denum, or  of  the  first  part  of  the  jejunum  through  a  laceration  in  the 
mesenter}^,  or  a  diverticulum  of  these  portions  of  the  intestine,  has 
brought  about  an  impediment  to  the  normal  course  of  the  ingesta, 
and  caused,  in  the  end,  a  gastric  dilation. 


PLATE  XIII. 


Y    *c 


?c 


.^^^   \ 


Malformation  and  Distortion  of  the  Stomach  Caused  by  Lacing  or  Tight 
Clothing,  Belts,  Etc. 

Figures  i,  2,  3,  and  4  illustrate  the  origin  of  the  loop  ff>rm  of  the  stomach  by  approxi- 
mation of  the  cardia  (C)  and  the  pylorus  (P).  Figures  5,  6,  and  7. illustrate  the 
vertical  position  and  descent  of  the  pylorus  (see  text). 


DUODENAL   ABNORMALITIES    AND    DILATION.  629 


ATONIC  DILATION. 

Gastric  atony  is  a  condition  of  reduced  or  lost  tonicity  of  the  mus- 
culature. It  is  a  state  of  sub-  or  hypotonicity,  also  very  aptly  desig- 
nated as  gastric  myasthenia.     (See  special  chapter  on  this  subject.) 

Dilations  resulting  from  this  state  that  seem  to  be  primary  may  be 
acute  or  chronic.  The  first  kind,  which  are  very  rare,  have  for  their 
cause  either  a  traumatism  or  a  surgical  intervention  (laparotomy),  or 
else  a  serious  infectious  disease;  Hilton  Fagge  (/.  c),  Bart  els  (/.  c), 
Montaya  (/.  c),  and  Lepoil  (/.  c.)  have  cited  examples  in  which  ty- 
phoid fever  seems  to  have  played  the  part  of  the  chief  cause.  In  this 
case  the  dilation  seems  to  be  due  to  the  loss  of  tonicity  of  the  muscu- 
lature of  the  stomach  and  of  the  abdomen.  In  other  cases  the  origin 
of  the  evil  is  an  excess  of  food,  an  error  committed  so  frequently  by 
convalescents  after  they  have  been  confined  to  one  diet  for  a  long 
time. 

Chronic  forms  of  atonic  dilations  are  dependent  upon  a  great  num- 
ber of  factors.  Those  addicted  to  excessive  indulgence  in  food  suffer 
first  with  distention  of  the  stomach ;  then,  later,  with  dilation.  This 
phenomenon  is  comparatively  frequent  with  persons  into  whose  ordi- 
nary diet  a  large  quantit}^  of  liquids  enters;  with  excessive  beer- 
drinkers,  for  instance,  the  beer  acting  not  only  mechanically  by  its 
volume,  but  also  through  the  irritating  and  poisonous  substances  with 
which  it  may  be  adulterated.  Debove  (/.  c.)  has  called  attention  to 
the  drawbacks  of  prescribing  milk  in  considerable  quantities,  and  has 
cited,  among  others,  a  case  of  circular  ulcer  cured  by  the  daily  allow- 
ance of  eight  liters  of  milk ;  but  an  enormous  dilation  of  the  stomach 
resulted.  In  the  chapter  on  Acute  Gastritis  we  have  pointed  out  that 
overfeeding  produces  a  certain  amount  of  gastritis.  The  dilation  is 
produced  under  this  double  influence  of  the  inflammation  and  of  the 
distention;  without  the  addition  of  the  first  of  these  causes,  megalo- 
gastria  alone  would  occur. 

Simple  chronic  gastritis  may  result  in  a  considerable  atrophy  of  the 
muscular  fibers  of  the  stomach,  which  may  lead  to  dilation  of  the  stom- 
ach. The  same  may  be  said  of  hyperchylia,  provided  that  it  is  one 
of  the  forms  where  a  hyperacid  secretion  causes  a  prolonged  stasis  of 
the  amylaceous  substances;  such  cases  have  been  collected  by  Ma- 
thieu  and  Remond,  under  the  name  of  dyspepsia  with  organic  hyper- 
acidity and  stasis.  In  other  cases  muscular  atony  is  the  result  of  a 
prolonged  retention  in  the  stomach  of  undigested  food,  with  fermen- 


630  MOTOR   INSUFFICIENCY. 

tation  thereof,  when  hydrochloric  acid  is  absent.  Drawn  out  by  a 
weight  more  or  less  considerable,  and  distended  by  the  gases  that  are 
developed  in  the  putrefying  mass,  the  muscular  fibers  gradually  be- 
come diseased  and  lose  their  elasticity.  The  dilation  found  in  con- 
sumptives, in  chlorosis,  etc.,  is  due  solely  to  chronic  gastritis,  which  is 
caused  by  asthenia  and  the  alterations  in  the  blood,  the  results  of 
these  diseases.  In  diabetes  both  the  chronic  gastritis  and  super- 
abundance of  food  cooperate  in  the  alteration  of  the  walls,  and  may 
finally  lead  to  amyloid  and  colloid  degenerations  of  the  muscular 
fibers. 

Atony  of  purely  nervous  origin,  concerning  which  the  French 
writers  Germain-See  {I.  c.)  and  Mathieu  {I.  c.)  have  published  numer- 
ous researches,  is  held  by  them  to  be  a  consequence  of  "crises,"  by 
which  term  they  mean  successive  and  alternating  intervention  of 
spasm  and  of  atony  of  the  gastro-intestinal  tract.  These  crises  are 
produced  by  an  occasional  and  general  cause,  such  as  sad  emotions, 
mental  shock,  neurasthenia,  etc. 

The  atonic  form  of  dilation  was  first  recognized,  toward  the  end  of 
the  last  century,  by  John  Peter  Frank  (/.  c),  who  separates  it  dis- 
tinctly from  the  forms  caused  by  stenosis.  The  atony  due  to  neu- 
rasthenia can  be  brought  about  by  lesion  of  the  central  or  peripheral 
nervous  system,  and  the  dilation  will  then  depend  on  a  deep-seated 
alteration  either  of  the  central  organs  or  of  the  peripheral  nerv^es. 
Bouveret,  Dujardin-Beaumetz,  and  Glenard  have  represented  general 
ptosis  of  the  abdominal  organs  as  the  expression  of  a  particular  dia- 
thesis, a  condition  of  relaxation  of  the  tissues  with  unstriated  mus- 
cular fibers;  and  have  suggested  that  there  is  a  dilation  depending 
upon  this  general  state.  The  dilations  resulting  from  nephroptosis 
are  included  in  this  class  by  Glenard,  Debove,  and  Remond.  (See 
Enteroptosis.) 

Pathological  Anatomy. — Having  already  considered  the  patho- 
logical histology  of  the  various  causes  of  dilation, — viz.,  neoplasms, 
benign  and  malignant  cicatrices,  chronic  interstitial  gastritis,  etc., 
— the  pathological  anatomy  of  the  dilation  per  se  is  simple.  At  the 
autopsy  of  a  subject  dead  from  cancer  of  the  pylorus,  for  instance, 
one  finds  the  abdomen  filled  by  a  voluminous  sac,  which  comes  down 
more  or  less  near  the  pubes.  This  sac,  which  represents  the  stomach, 
having  lost  all  its  normal  relations,  and  excessively  dilated,  may  con- 
tain enormous  quantities  of  liquid,  and  the  ancient  authors,  who 
knew  only  the  extreme  cases,  have  cited  extraordinary  examples  of 


SYMPTOMATOLOGY   OF   MOTOR   INSUFFICIENCY.  63 1 

this.  (The  history  of  the  subject  is  given  by  Penzoldt,  ' '  Die  Magener- 
weiterung,"  Erlangen,  1875.)  Plempius  (/.  c.)  is  said  to  have  seen 
a  stomach  that  held  nine  pints  of  liquid ;  Stengel  mentions  a  stomach 
containing  12  "measures";  Schurig,  a  stomach  containing  48  liters; 
Henricus  ab  Herr  found  a  stomach  that  filled  the  whole  of  the  abdo- 
men. Portal  (quoted  by  Ewald  and  Pick)  states  that  the  stomach  of 
the  Duke  of  Chausnes,  one  of  the  greatest  gourmands  of  his  time,  had 
a  capacity  of  4^  liters.  The  largest  stomach  observed  by  the  author 
had  a  capacity  of  4  liters,  measured  by  his  method. 

All  the  layers  of  the  walls  of  the  gastric  sac  have  become  thin ;  and 
microscopically  one  finds  atrophy  of  the  mucosa;  at  the  same  time 
the  muscularis  is  now  composed  only  of  isolated  bunches  of  muscular 
fibers,  separated  by  the  connective  tissue.  When  the  dilation  is 
caused  by  an  obstruction  at  the  pylorus,  hypertrophy  of  the  muscular 
wall  is,  as  a  rule,  produced  first ;  then  interstitial  sclerosis  comes  on, 
little  by  little,  submerging  the  true  elements,  and  the  final  atony  of 
the  wall  is  due  to  the  disappearance  of  the  contractile  fibers.  An 
apparent  hypertrophy,  through  exaggerated  proliferation  of  the  con- 
nective tissue,  sometimes  masks  the  actual  atrophy  of  muscle-fibers 
in  these  cases  which  occasionally  can  not  be  distinguished  from  scir- 
rhus,  even  microscopically.  The  muscular  hypertrophy  continues 
very  long  in  the  pyloric  region,  where  it  also  attains  its  maximum 
point.  The  increased  resistance  and  thickening  of  the  walls  some- 
times results  from  ulcer,  and  may  simulate  a  tumor. 

A  dilated  stomach  may  present  variable  forms  due  to  the  action  of 
the  special  cause.  If  a  cicatricial  or  scirrhous  constriction  causes  the 
cardia  and  the  pylorus  to  approach  each  other,  the  stomach  will  be 
pyriform;  but  if  the  same  lesion  has  plowed  a  transverse  furrow, 
more  or  less  deep,  on  the  wall,  a  dilation  in  the  shape  of  an  hour-glass 
will  be  produced ;  but  the  symptoms  do  not  differ  from  those  caused 
by  occlusion  of  the  pylorus. 

Symptomatology. — The  tongue  is,  in  most  cases,  coated  by  necro- 
biotic  epithelium,  mucus,  and  retained  food  debris,  the  breath  fre- 
quently being  very  offensive ;  there  is  generally  a  stomatitis,  glossitis, 
or  gingivitis  present. 

State  of  the  Appetite. — The  appetite  is  normal  at  the  beginning; 
but  when  the  disease  has  developed,  it  may  be  lost  or  may  become 
considerably  decreased:  some  patients,  for  instance,  will  not  need 
more  than  one  meal  a  day.  In  other  cases,  since  the  stomach  merely 
plays  the  part  of  a  reservoir  with  no  outlet,  and  the  foods  are  no 
42 


632  MOTOR   INSUFFICIENCY. 

longer  evacuated  from  the  stomach  into  the  intestine,  digestion  and 
absorption  can  not  occur.  In  rare  instances  the  patients  may  be 
tormented  with  hunger,  and  they  are  in  a  condition  analogous,  so  far 
as  effects  are  concerned,  to  that  of  persons  affected  with  an  impassable 
stenosis  of  the  esophagus.  They  try  to  satisfy  their  appetites,  and, 
yielding  to  the  solicitation  of  hunger,  actuall}^  present  bulimic  phe- 
nomena. In  reality  it  is  not  hard  to  understand  this  difference,  which 
depends  practically  on  the  nature  of  the  obstruction  to  the  course  of 
the  foods ;  anorexia  is  observed  chiefly  in  cancerous  patients  and  in 
those  seized  with  chronic  gastritis,  while  a  cicatrix  of  a  circular  ulcer 
may  have  obliterated  the  pylorus  without  bringing  about  serious  loss 
of  appetite. 

Pyrosis. — The  regurgitation  of  a  certain  quantity  of  very  acid  or 
alkaline  ingesta  often  accompanies  the  eructations  that  pass  through 
the  cardia,  causing  intense  pyrosis. 

Eructations  and  Gaseous  Discharges. — In  motor  insufficiency  of  the 
first  degree  the  gastric  heaviness  and  the  distention  give  way  little  by 
little,  and  if  the  patient  takes  his  meals  at  regular  intervals,  his 
stomach  at  last  empties  itself  and  his  pains  disappear.  But  in  motor 
insufficienc)^  of  the  second  degree  generall)^  the  distress  ceases  only 
when  more  or  less  copious  emesis  has  relieved  the  gastric  cavity  of  the 
foods  that  have  burdened  it,  sometimes  for  more  than  twenty-four 
hours. 

To  this  feeling  of  fullness  are  added  disgusting  gaseous  discharges, 
often  very  fetid.  The  alimentary  contents,  in  fact,  are  liable  to  set 
free  many  different  gases  in  considerable  quantity.  (See  chapter  on 
the  Gases  of  the  Stomach.)  The  principal  gases  are  carbonic  acid, 
hydrogen,  oxygen,  nitrogen,  hydrogen-sulphid,  and  carbonic  dioxid. 
Whenever  there  is  stasis,  presence  of  gases  may  be  verified  by  directly 
extracting  them  from  the  stomach  by  the  tube  or  by  allowing  the 
drawn  gastric  contents  to  stand  in  a  closed  vessel.  This  gaseous 
development  is  due  to  bacteria  which  may  resist  the  antiseptic  action 
of  the  hydrochloric  acid,  even  when  present  in  excess ;  some  of  these 
organisms  have  been  isolated  and  cultivated.  These  fermentations, 
which  are  very  frequent,  are  modified  by  salicylic  acid  or  saccharin. 
Boric  acid,  carbolic  acid,  creasote,  and  chlorin  water  have  no  decided 
effect,  in  my  experience,  except  in  doses  that  are  incompatible  with 
their  therapeutic  uses.  The  great  quantity  of  liquid  contained  in  the 
stomach  facilitates  the  development  of  anaerobic  germs,  giving  rise  to 
complex  and  toxic  products  of  fermentation. 


PAIN,    VOMITING,    ETC.  633 

Pain. — The  pain  of  dilation  is  not  marked;  the  uncomfortable 
sensations  are  those  of  pressure,  fullness,  and  distention.  Naturally, 
if  cancer  or  ulcer  is  coexistent  with  dilation,  pain  will  be  a  prominent 
symptom. 

Vomiting. — In  motor  insufficiency  of  the  second  degree  the  attacks 
of  emesis  are  quite  characteristic.  They  are  not  so  frequent  as  they 
are  at  certain  stages  of  the  development  of  cancer  or  of  ulcer,  and  are 
generally  separated  from  each  other  by  variable  but  comparatively 
long  periods,  and  they  rarely  occur  at  the  time  of  the  maximum  of 
digestion.  For  one  or  two  days  a  patient  suffers,  after  each  meal, 
from  a  sensation  of  growing  uneasiness,  and  from  a  feeling  of  weight 
in  the  epigastrium,  more  and  more  painful;  then,  suddenly,  often 
toward  the  middle  of  the  night,  he  is  seized  with  very  abundant  vom- 
itings, after  which  he  can  enjo}^  a  little  rest. 

The  vomited  material  is  sometimes  composed  of  several  liters  of  a 
mixture  of  solid  food,  drinks,  and  mucus.  The  quantity  of  vomited 
matter  is  a  first-rate  symptom  of  dilation,  and  allows  it  to  be  distin- 
guished, for  instance,  from  simple  displacements  of  the  stomach. 
Chronic  gastritis,  cancer,  etc.,  may  also  give  rise  to  slight  hemor- 
rhages, and  in  this  case  the  very  much  modified  blood  remains  a  long 
while  in  the  stomach;  the  same  phenomenon  can  be  recognized  in 
dilation. 

Boas  has  pointed  out  that  the  persistent  presence  of  bile  and  of 
pancreatic  fluid — of  which  the  characteristics  have  been  given — is 
an  indication  of  stenosis  of  the  duodenum,  and  is  a  valuable  symp- 
tom of  dilation  resulting  from  the  compression  of  this  part  of  the  in- 
testine by  a  dilated  gall-bladder  or  hepatic  neoplasm,  for  instance. 
The  vomited  matter  will  have  a  more  offensive  odor  the  longer  it  has 
remained  in  the  stomach.  Later  on  in  the  disease,  when  the  walls  are 
distended,  the  vomiting  comes  on  at  greater  intervals,  the  odor  of 
substances  vomited  becomes  more  revolting,  and  then  the  emesis  is 
rarely  sufiicient  to  evacuate  the  stomach ;  the  feeling  of  relief  which 
at  first  followed  is  no  longer  experienced.  Sometimes  the  vomitings 
cease  after  they  have  been  very  frequent — a  grave  sign  of  exhaustion. 

Symptoms  of  autointoxication  from  dilation  have  been  described  by 
Al.  Pick  ("Wien.  klin.Wochenschr.,"  1892,  No.  46),  Boas  {I.e.,  p.  73), 
and  J.  Friedenwald  ("Med.  News,"  Dec.  23,  1893).  A  most  exhaus- 
tive account  of  the  autointoxication  with  motor  insufficiency  will  be 
found  in  the  works  of  Albu  (/.  c.)  and  Bouveret  (/.  c). 

In  dilation  through  an  organic  cause  the  disturbance  of  the  general 


634  MOTOR  INSUFFICIENCY. 

state  will  vary  with  this  cause.  Thus,  it  is  observed  that  in  cancer- 
ous patients  the  dilation  is  accompanied  by  the  most  evident  cach- 
exia. In  ulcer,  Reichmann's  disease,  and  chronic  gastritis,  dilation 
will  be  coincident  with  an  emaciation  more  or  less  marked,  but  no 
cachexia. 

In  the  case  of  children,  Comby  and  Moncorro  have  attributed  to 
dilation  caused  by  overfeeding  a  role  in  the  etiology  of  rachitis.  The 
latter  author  also  considers  it  to  be  the  cause  of  certain  convulsions, 
of  insomnia,  of  ringworms,  of  urticaria,  and  of  bronchitis. 

Constipation. — Constipation  is  frequent  and  obstinate;  and  not 
only  are  the  stools  rare,  but  the  quantity  of  substances  evacuated  is 
also  much  less  than  in  the  normal  state.  This  is  a  very  valuable  indi- 
cation, for  it  shows  the  approximate  amount  of  food  that  passes  into 
the  intestines.  From  four  to  six  ounces  of  solid  feces  are  normally 
discharged  in  twenty-four  hours.  In  atonic  dilation  this  amount  is 
reduced  to  2  J  ounces,  and  in  extreme  cases  to  i^  ounces,  in  twenty- 
four  hours,  on  the  average.  The  amount  of  water  in  the  feces  is  nor- 
mally 75  per  cent. ;  this  is  reduced  to  from  30  to  40  per  cent,  in  dila- 
tion. The  prognosis  is  influenced  by  the  degree  to  which  food  may 
be  made  to  take  its  normal  course  (Kussmaul) .  Persistent  constipa- 
tion or  absence  of  stools  indicates  an  incurable  stenosis  of  the  pylorus. 
Putrefactive  diarrhea  may  alternate  with  constipation. 

Gastrorrhexis  (Rupture  of  the  Stomach). — Newmann  (/.  c),  Buist 
(I.  c),  Lautschner  (/.  c),  and  Hoffmann  have  reported  rupture  of  the 
stomach  and  sudden  extravasation  of  its  contents  into  the  peritoneal 
cavity.  Rupture  may  occur  after  a  very  sudden,  acute  dilation,  or 
in  the  last  stage  of  one  of  long  standing.  The  tear  generally  occurs 
near  an  old  cicatrix.  A  case  reported  by  Chiari  (Z.  c.)  has  a  cicatrix 
near  the  lesser  curvature,  through  which  the  tear  occurred  after  over- 
indulgence in  food.  In  a  case  observed  by  Hoffmann  (I.  c),  in  which 
a  rupture  of  the  lesser  curvature  had  taken  place,  no  other  cause  but 
food  engorgement  was  assigned. 

State  of  the  Urine. — The  quantity  passed  in  twenty-four  hours  may 
be  reduced  to  500  c.c.  Boas  makes  use  of  the  daily  quantity  for  an 
approximate  estimate  of  the  degree  of  dilation. 

First  degree.      Quantity  of  urine  in  twenty-four  hours,  1500  to  icoo  gm. 
Second       "  "  "  "  "        1 000  to    500    " 

Third      "  "  "  "  "         500  gm.   and  less. 

The  urine  is  generally  alkaline  ;    the  chlorids  are  diminished. 

The  urine  is  frequently  modified  in  quantity  and  in  quality.     The 


STATE   OF    URINE,    BOWELS,    ETC.  635 

patients  are  in  a  state  of  chronic  inanition,  and  the  urea  is  therefore 
necessarily  diminished.  The  stomach  absorbs  Httle  Hquid,  as  the 
constant  thirst  by  which  these  patients  are  tormented  testifies ;  thus 
the  dilation  brings  about  a  deficient  urinars^  secretion.  Lastly,  when 
the  dilation  accompanies  an  excessive  secretion  of  hydrochloric  acid, 
and  the  latter  is  thrown  out,  either  by  frequent  vomitings  or  by  fre- 
quent lavage,  the  urine  becomes  alkaline. 

Nervous  Phenomena. — Erb  found  increased  galvanic  and  faradic 
irritability  of  all  accessible  motor  nerves,  with  the  exception  of  the 
facial.  The  increase  of  the  galvanic  irritability  of  the  nerves  is  a  more 
constant  symptom  than  the  increase  of  faradic  irritability.  Von 
Frankl-Hochwart  found  the  latter  to  be  normal  at  times.  Trousseau 
found  that  tetany  could  be  caused  by  compression  of  the  main  nerv'e- 
trunks  or  compressing  the  principal  blood-vessels  of  the  limbs,  so  that 
the  arterial  and  venous  circulation  was  impeded.  When  this  com- 
pression was  kept  up  for  two  or  three  minutes,  the  tetany  began,  but 
would  cease  when  the  pressure  was  relieved.  Chvostek  discovered 
an  increase  of  mechanical  irritability  of  the  nerves  in  the  extremities, 
and  also  of  the  facial  nerve  in  particular.  This  irritability  became 
evident  on  tapping  the  nerv^es  lightly  with  a  percussion  hammer  or 
with  the  finger,  which  brought  on  rapid  instantaneous  twitchings  in 
the  muscles  supplied  by  those  nerves.  On  passing  the  finger  over  the 
face  from  the  temporal  regions  down  to  the  chin,  distinct  twitchings 
occurred  in  the  muscles  supplied  by  the  facial  nerve,  because  this 
stroke  of  the  finger  exerted  an  irritation  on  all  branches  of  that  nerve 
(Fr.  Sthultze). 

General  State  of  Health. — The  general  state  of  health  is  more  deeply 
influenced  by  the  cause  of  the  dilation  than  by  the  dilation  itself. 
Neurasthenia  often  causes  an  atony  of  the  muscle-fibers  of  the  stom- 
ach, the  consequences  of  which  can  not  but  have  a  marked  influence 
on  the  nutrition  of  the  patient,  encouraging  and  keeping  up  the  neu- 
rasthenia. Diabetes,  chlorosis,  and  great  pyrexia,  which  may  have 
caused  the  atony,  provoke  general  disorders  also,  and  it  is  difficult  to 
distinguish  from  among  the  resulting  disturbances  that  which  belongs 
properly  to  gastric  atony. 

Cardiopulmonary  Symptoms. — These  have  been  considered  in  the 
chapter  on  the  Influence  of  Gastric  Diseases  on  Other  Organs,  in 
which  I  have  dwelt  on  the  effects  of  distention  of  the  gastric  cavity  by 
gases  hindering  considerably  the  functions  of  the  diaphragm  and  dis- 
turbing the  action  of  the  respiratory  and  circulatory  apparatus. 


636  MOTOR   INSUFFICIENCY. 

Dyspneic  phenomena,  or  modifications  in  the  sound  of  the  heart  and 
in  the  rhythm  of  the  pulse,  are  frequently  met  with. 

Mattheides  (/.  c.)  has  gathered  together  a  number  of  cases  in  which 
he  observed  a  sensation  analogous  to  that  of  globus  hystericus  in 
patients  afflicted  with  dilation.  He  called  attention  to  the  fact  that 
this  sensation  was  aggravated  when  the  stomach  had  sunk;  on  the 
other  hand,  it  diminished  when  it  had  risen ;  from  this  he  concluded 
that  the  displacement  of  the  stomach  so  often  accompanying  the 
dilation  of  this  organ  was  the  cause  of  this  sensation  of  globus, 
through  dragging  on  the  esophagus.  Schmidt  {I.  c.)  is  said  to  have 
verified,  by  a  laparotomy,  the  existence  of  these  anatomical  disorders 
in  a  patient  who  had  previously  complained  of  the  sensation  of  globus. 
The  connection  between  the  two  is  not  at  all  satisfactorily  proved,  or 
even  significant. 

Percussion,  Palpation,  and  Auscultatory  Percussion  of  the 
Stomach, — Osier  (/.  c.)  emphasizes  the  fact  that  the  diagnosis  is  often 
possible  by  inspection.  Percussion  and  palpation  allow  us  to  ascer- 
tain the  limits  of  the  lower  edge  of  the  greater  curvature,  and,  to  a  cer- 
tain extent,  to  appreciate  the  degree  of  the  ectasia.  The  percussion 
should  be  performed  with  the  patient  standing  up,  and  again  when 
lying  on  his  back.  The  measured  ingestion  of  a  certain  quantity  of 
water  will  allow  one  to  estimate  the  atony  of  the  wall,  and  will 
at  the  same  time  furnish  exact  data  on  the  displacement  of  the 
lower  edge  of  the  organ.  The  stomach  may  be  distended  by 
CO2,  and  the  colon  by  water,  thus  facilitating  the  differentia- 
tion between  the  two.  Other  authors  have  proposed  to  perform 
the  operation  inversely,  and  to  percuss  the  stomach  made  heavy 
by  a  certain  quantity  of  water,  while  the  colon  is  distended  by 
gas  (Ewald).  Auscultatory  percussion — i.  e.,  percussing  over  the 
abdomen  while  a  phonendoscope  is  simultaneously  moved  over 
it  and  in  constant  connection  with  the  ears — is  of  service  in 
delineating  the  outlines  of  the  stomach  (A.  T.  Benedict).  These 
precautions  would  make  mistakes  very  difficult;  they  are  avail- 
able to  general  practitioners,  which  can  not  be  said  of  the 
Rontgen  rays  and  the  electrodiaphane.  Osier  holds  that  when  the 
distended  stomach  is  outlined  on  the  abdominal  wall,  one  can  usually 
follow  its  delineations  with  the  eye,  and,  of  course,  much  better  by 
percussion.  In  the  "Philadelphia  Medical  Times"  for  May,  1891, 
Pepper  reports  a  case  of  dilation  caused  by  scirrhus  of  the  pylorus 
in  which  there  was  a  visible  peristalsis. 


RESUIvT   Olf   PERCUSSION   AND   PALPATION. 


637 


-^:l 


The  gaseous  distention  has  also  the  advantage  that  it  allows  the 
distinction  to  be  made  between  true  dilation  and  a  simple  displace- 
ment of  the  organ. 

By  palpation  the  splashing  sound  can  be  investigated.  This  is  easy 
to  perceive  when  the  stomach,  the  pylorus  of  which  is  constricted,  is 
full  of  those  liquid  masses  already  mentioned  in  connection  with  the 
vomiting.  But  when  the  dilation  is  not  very  marked,  the  splashing 
becomes  less  clear,  and  Debove  has  recently  shown  that  the  intestines, 
when  half  distended  by  gases,  are  capable,  under  the  influence  of 
movements  communicated  by  the  fingers,  of  producing  a  sound  so  like 
that  of  the  gastric  splashing  as  to 
make  the  distinction  very  difficult. 
Chomel  (/.  c.)  had  already  drawn  at- 
tention to  this  source  of  mistakes, 
and  to  that  which  depends  on  the 
presence  of  liquid  and  gas  in  the 
large  intestine:  "The  splashing  in 
the  stomach,"  he  says,  "might  be 
confounded  with  a  similar  sound  of 
which  the  large  intestine  is  some- 
times the  seat,  which  can  be  pro- 
duced by  the  lateral  movement  of 
the  body,  but  still  more  easily  by 
the  pressure  of  the  hand  on  the  re- 
gions occupied  by  the  colon."  It 
is  met  with  especially  in  subjects 
who  have  recently  received  an  injec- 
tion, and  in  those  who  have  been 
seized  with  serous  diarrhea.  The 
knowledge  of  these  conditions  and 

of  the  particular  source  of  the  gastric  splashing  sound  is  sufficient  to 
distinguish  it  from  intestinal  splashing.  Jaworski  (/.  c.)  has  reported 
four  cases  of  very  audible  splashing  sound  even  when,  on  introducing 
the  probe  into  the  stomach,  he  had  been  unable  to  withdraw  any 
liquid  whatever.  The  author  has  observed  this  fact  in  a  number  of 
cases.     It  is  not,  therefore,  an  unmistakable  sign. 

For  determining  the  location  of  the  greater  curvature,  Thiebaut 
(Z.  c),  of  Nancy,  has  devised  an  instrument  that  consists  of  a  probe 
through  which  slides  a  thread  with  a  leaden  weight.  The  probe  is 
long  enough  to  reach  the  cardia,  and  the  quantity  of  thread  taken 


1 


^ 


Fig.  41 


Dilation  of  Stomach. — 
{Eichhorst.) 
Outline  obtained  by  percussion. 


638  MOTOR  INSUFFICIENCY. 

by  the  leaden  weight  before  it  arrives  at  the  bottom  of  the  stomach 
allows  one  to  measure  the  vertical  dimension  of  the  gastric  cavity. 
This  method  impresses  me  as  fallacious. 

The  methods  of  procedure  based  on  the  employment  of  salol,  oil, 
iodid  of  potassium,  etc.,  designed  to  determine  the  state  of  the  motor 
functions  and  of  the  absorption  of  the  mucous  membrane,  have  been 
described.  In  dilation  they  give  information  of  varvdng  value,  but 
inferior  to  that  furnished  by  exploration  with  the  sound.  Dr.  Harry 
Adler  and  myself  have  been  able  to  map  out  the  greater  curvature 
with  ease  by  means  of  a  metallic  spiral  sound  inclosed  in  a  stomach- 
tube  (Kuhn,  Turck,  Wegele).  The  sound  is  readily  palpable.  I 
have  already  stated  the  signs  by  which  one  can  recognize  atony  of  a 
muscular  wall :  either  presence  of  debris  of  food  in  the  morning  before 
breakfast,  or  the  prolonged  retention  of  a  test-meal  in  the  gastric 
cavity.  The  Hemmeter  gastrograph  is  a  graphic  method  of  obtain- 
ing motor  records  from  the  human  stomach,  and  the  results  obtained 
therewith  are  generally  reliable.  (Plates  iii  and  iv,  between  pp.  76 
and  77.) 

Test-meals. — The  gastric  cavity  should  be  washed  out  on  the  even- 
ing of  the  day  before  a  test-meal  is  given.  The  substances  extracted 
by  this  preliminary  lavage  are  sometimes  very  abundant,  and  have 
the  same  composition  as  those  vomited.  They  generally  become 
separated  into  three  layers  when  allowed  to  stand:  an  upper  one, 
frothy  and  turbid ;  a  middle  one,  liquid ;  and  a  lower  one,  composed 
of  alimentary  detritus  of  all  kinds,  or  simply  of  amylaceous  sub- 
stances (hyperacidity).  Organic  ferments  and  sarcinae  will  be  dis- 
covered, and  all  the  series  of  products  that  can,  normally  or  abnor- 
mally, be  contained  in  the  stomach.  If  the  motor  insufficiency  is 
caused  by  malignant  neoplasm,  the  Oppler-Boas  bacillus  will,  as  a 
rule,  be  found  in  this  material.  In  the  morning  before  breakfast  the 
gastric  cavity,  which  has  been  cleansed  the  evening  before,  may  again 
contain  the  normal  products  of  secretion,  or  material  which  is  rich  in 
organic  acids.  The  digestion  of  the  test-meal  will  generall)^  be  slow, 
and,  especially  in  cases  of  cancer,  it  will  be  impossible  to  detect  free 
hydrochloric  acid.  In  other  patients  a  normal  or  exaggerated  state 
of  secretion  of  hydrochloric  acid  will  be  found.  When  the  normal 
HCl  is  absent,  the  filtered  gastric  contents  will  show  excess  of  lactic 
and  butyric  acids.  If  the  motor  insufficienc}"  is  due  to  alcoholism, 
acetic  acid  will  be  a  prominent  constituent. 

Diagnosis. — Dilation  or  motor  insufficiency  of  the  second  degree 


DIFFERENTIAL  DIAGNOSIS.  639 

may  have  to  be  differentiated  from  atony,  or  myasthenia  from  gastrop- 
tosis  and  physiologically  large  stomach,  or  megalogastria.  No  sign, 
unless  it  is  the  presence  in  notable  quantity  of  food  in  the  stomach 
before  breakfast,  is  pathognomonic.  Bugge  (l.  c.)  recommended  the 
following  operation :  After  determining,  by  percussion, — the  patient 
standing  up, — the  lower  edge  of  the  stomach,  he  drove  the  needle  of  a 
hypodermic  syringe  above  the  discovered  limit.  If  the  liquid  ex- 
tracted was  acid,  he  concluded  that  the  stomach  had  been  reached. 
It  is  evident  that  this  procedure  is  not  without  danger,  and  it  is  not 
even  accurate. 

I  prefer  the  simple  exploration  by  means  of  the  sound,  associated  or 
not  with  artificial  gaseous  distention  of  the  stomach ;  these  are  the 
most  available  and  practical  methods  for  the  general  practitioner, 
and,  in  fact,  suffice  to  distinguish  a  dilated  from  a  displaced  stomach, 
and  from  a  naturally  large  stomach.  But  if  they  do  not,  the  method 
of  the  author  (p.  76)  will  leave  no  room  for  doubt. 

Gastroptosis  (displacement  of  the  stomach)  will  be  fully  considered 
in  a  special  chapter  on  that  subject.  The  pylorus  may  be  displaced, 
and  may  be  freely  movable  below  the  epigastric  region,  without  in 
reality  causing  any  gastric  disturbance.  By  palpation  and  percus- 
sion the  greater  curvature  of  the  stomach  can  be  made  out  below  the 
umbilicus.  One  might  then  be  very  much  disposed  to  suspect  a  dila- 
tion; but  on  distention  with  CO,  gas,  one  sees  not  only  the  greater, 
but  also  the  smaller,  curvature  outlined  under  the  skin,  and  the  out- 
line of  the  whole  stomach  can  be  traced  on  the  abdominal  wall,  and 
the  limits  of  the  corresponding  resonant  zone  can  be  ascertained  by 
percussion. 

The  points  of  difference  between  a  dilation  and  atony  are  the  fol- 
lowing: In  the  morning,  before  food  has  been  ingested,  the  dilated 
stomach  contains  an  accumulation  of  putrefactive  products  and  food 
material,  showing  either  excess  of  lactic  and  fatty  acids  or,  when 
these  are  absent,  abnormal  amounts  of  HCl.  In  simple  atony  the 
stomach  is,  as  a  rule,  entirely  empty  in  the  morning;  in  atonic  dila- 
tion it  may  contain  trifling  amounts  of  food,  but  not  in  a  state  of  de- 
composition. In  atony  the  bowel  evacuations  are  less  likely  to  be  so 
few  in  number  and  so  small  in  amount,  and  the  total  quantity  of 
urine  voided  in  twenty-four  hours  is  normal  or  only  slightly  reduced. 
In  dilation  the  amount  of  urine  is  subnormal,  and  it  is  concentrated 
and  in  rare  cases  contains  diacetic  acid  and  acetone. 

In  megalogastria  we  are  not  dealing  with  a  diseased  stomach,  and 


640  MOTOR   INSUFFICIENCY. 

hence  a  differentiation  is  unnecessary  Tetany  occurs  only  with 
dilation,  but  gastric  vertigo  is  frequent  in  aton^^  The  differentiation 
between  a  dislocated  and  a  dilated  stomach  is  facilitated  by  the  clini- 
cal histor3^  In  a  dislocated  stomach  the  motor  function  is  frequently 
normal,  and  hence  we  find  that  emesis,  if  it  occurs,  does  not  bring 
out  such  ver}^  large  amounts  as  in  dilation.  Diuresis  and  thirst  are 
normal  in  gastroptosis ;  in  dilation  thirst  is  intense,  but  on  account 
of  the  regurgitation  or  vomiting  of  fluids,  diuresis  is  subnormal.  No 
matter  where  a  stomach  may  be  located  within  the  abdomen,  or  how 
large  it  may  be,  it  does  not  become  abnormal  until  the  motor  function 
is  interfered  with.  A  Leube  or  Herschell  test-meal  or  the  Salzer 
double  test-meal  will  instruct  us  concerning  these  points. 

The  success  of  inspection,  palpation,  and  percussion  will  depend 
upon  the  thickness  and  resistance  of  the  external  abdominal  wall. 
When  there  is  very  little  or  no  emaciation,  it  is  b}^  no  means  easy  to 
palpate  through  the  abdominal  wall.  Then,  again,  much  gas  escapes 
into  the  intestine  when  the  stomach  is  distended  by  effervescent 
mixtures. 

But  by  means  of  the  author's  stomach-shaped  intragastric  rubber 
bag,  or  by  Einhorn's  electrodiaphane,  it  is  possible  to  make  the  differ- 
ential diagnosis  without  much  difficulty.  By  the  Hemmeter  appara- 
tus, which  was  originally  designed  to  obtain  records  of  the  gastric 
peristalsis,  it  is  also  possible  to  measure  the  capacity  of  the  stomach 
by  determining  the  amount  of  air  required  to  distend  it  within  the 
stomach.  (See  p.  79.)  This  will  at  once  enable  one  to  diagnose  a 
dilated  stomach  from  one  that  has  prolapsed  but  has  retained  its 
normal  capacity.  Einhorn's  diaphane  is  a  practical  method  for 
demonstrating  these  two  conditions  to  the  eye.  (See  special  article 
on  Diaphany.)  The  Roentgen  rays  are  also  available  for  the  same 
purpose,  as  demonstrated  by  the  author.  (Hemmeter,  ' '  Photography 
of  the  Human  Stomach  by  the  Roentgen  Rays,"  ' '  Boston  Medical  and 
Surgical  Journal,"  1896.)  Recently  the  author  has  used  the  follow- 
ing method :  The  dilated  stomach  is  coated  internally  with  bismuth 
subnitrate  by  means  of  the  stomach  powder-blower;  thereafter  its 
outline  can  be  distinctly  recognized  through  the  fluoroscope.  The 
greater  curvature  may  be  outlined  by  photographing,  by  the  Roentgen 
rays,  a  metallic  spiral  electrode  that  has  been  introduced  and  made 
to  apply  itself  along  the  greater  curA^ature,  according  to  suggestions 
first  made  by  Wegele.  For  private  practice  distention  and  the  Ein- 
horn  electrodiaphane  are  most  expedient,  as  they  perm.it  a  diagnosis 


PLATE  XIV. 


Gastrectasia. 
Transillumination  (electrodiaphany)  of  the  stomach.      The  organ   is  filled  with  600  c.c. 
of  water,  and  has  sunk  downward  to  the  left.      The  electric  lamp  has  just  reached 
the  fundus;    on  being  pushed   further,   the  intensest  part  of  the  transillumination 
would  appear  below  the  umbilicus. 


DIFFERENTIAL   DIAGNOSIS.  64 1 

to  be  made  by  inspection.  Debove  and  Remond  ("Maladies  de 
rEstomac,"  p.  87)  state  that  the  execution  of  this  method  is  difficult, 
and  imposes  much  suffering  upon  the  patient.  From  what  I  have  seen 
almost  weekly  with  Einhorn's  apparatus,  I  differ  emphatically  from 
these  observers,  and  believe  a  further  experience  with  the  apparatus 
will  effect  a  change  in  their  opinion. 

Diagnosis  of  the  Cause. — The  cause  is  more  difficult  to  detect  than 
the  dilatation  itself.  In  this  connection  I  refer  to  what  has  been  said 
in  the  consideration  of  ulcer,  carcinoma,  benign  neoplasms,  etc.,  and 
their  respective  diagnoses. 

The  anamnesis,  the  examination  of  the  substances  vomited,  and 
the  results  furnished  by  test-meals  will  provide  the  principal  data. 
The  clinical  history  differs,  in  fact,  considerably,  according  as  one 
finds  a  dilation  of  cancerous  origin  or  one  caused  by  ulcer  or  gastri- 
tis. The  effects  of  the  ingestion  of  poisons  have  been  considered 
under  Toxic  Gastritis.  The  corrosive  poisons  frequently  produce  a 
cicatricial  contraction  of  the  pylorus.  The  significance  of  HCl  in 
the  gastric  contents  has  been  stated  in  the  chapter  on  Carcinoma. 
If  the  bile  is  always  absent  in  the  substances  vomited,  or  in  the 
gastric  contents  either  before  or  after  eating,  one  will  be  led  to  think 
of  constriction  of  the  pylorus;  this  will  probably  be  of  cancerous 
origin  if  the  hydrochloric  acid  is  missing  at  the  same  time. 

The  constant  presence  of  bile  and  of  pancreatic  juice  in  the  stomach 
would  be  a  proof  that  the  dilation  is  a  consequence  of  a  stenosis  of  the 
duodenum,  which  may  result  from  a  movable  kidney,  a  fibrous  adhe- 
sion, gall-stones,  pancreatic,  cystic,  or  hepatic  neoplasm,  etc. 

The  author  has  devised  a  method  by  which  a  stenosis  of  the  pylorus 
and  of  the  duodenum  can  be  accurately  determined.  (Hemmeter, 
"Intubation  des  Duodenum,"  "Archiv  f.  Verdauungskrankh.,"  Bd. 
II,  S.  85.     See  also  Part  First,  this  volume.) 

F.  Kuhn,  who  belongs  to  Riegel's  school  (Giessen),  has  also  devised 
a  method  for  sounding  the  pylorus,  which  is,  however,  a  development 
of  a  revolving  spiral  sound  first  invented  by  F.  B.  Turck,  of  Chicago. 
The  Turck-Kuhn  method  is  very  ingenious  and  simple ;  but  owing  to 
the  necessity  of  revolving  of  the  spiral  sound  within  the  stomach,  the 
method  is  not  free  from  danger  in  cases  in  which  we  should  suspect 
open  ulcers  or  carcinoma,  since  the  intragastric  revolutions  or  the 
sound  may  bruise  or  tear  the  ulcer  or  neoplasm  and  set  up  hemor- 
rhage or  lead  to  perforation. 

The  accuracy  of  these  results,  it  is  true,  is  not  absolute;  but  in 


642  MOTOR   INSUFFICIENCY. 

practice,  in  associating  them  with  other  data  furnished  by  the  ele- 
ments of  the  diagnosis  of  each  gastric  affection,  a  diagnosis  should,  as 
a  rule,  be  attainable. 

Prognosis. — The  evolution  of  motor  insufficiency  varies  according 
to  the  cause ;  when  it  is  a  case  of  simple  atony  of  recent  date,  a  proper 
treatment — of  which  I  shall  speak  again  further  on — may  bring  amel- 
ioration rapidl}^,  and  even  cure.  But  when  it  is  a  case  of  dilation  with 
atrophy  of  the  muscular  coat,  especially  when  there  exists  an  impas- 
sable obstacle  at  the  pylorus,  the  cure  is  impossible,  except  sometimes 
by  operation;  The  treatment  still  relieves  the  painful  phenomena, 
but  the  inanition  makes  progress  from  day  to  day,  and  the  patient 
succumbs  gradually,  unless  one  of  the  complications  that  have  been 
mentioned  appears  and  hastens  the  end. 

Malformations  of  the  Gastric  Cavity. — For  literature,  see  article 
by  H.  W. Bettman,  "TheShape  and  Position  of  the  Stomach"  ("Phila- 
delphia Monthly  Medical  Journal,"  vol.  i,  p.  121),  containing  im- 
portant anatomical  contributions  to  this  subject.  As  dilation  is,  in 
reality,  a  deformity  of  the  stomach,  a  certain  number  of  malforma- 
tions and  changes  of  form  may  be  appropriately  considered  in  this 
connection. 

According  to  Debove  and  Remond,  atresia  of  the  gastric  cavity 
results  from  diminution  of  work  by  the  organ,  through  insufficiency 
of  alimentary  contributions.  Inanition  and  constriction  of  the 
esophagus  or  of  the  cardia  will  thus  have  been  the  first  cause  of  this 
atrophy.  In  other  cases  it  is  a  cancerous  infiltration,  extending  over 
the  whole  wall,  or  a  chronic  gastritis  with  hypertrophy  of  the  sub- 
mucosa  and  of  the  connective  tissue  (linitis  plastica),  or  a  fibrous, 
deforming  peritonitis,  which  will  have  played  the  same  part.  The 
caliber  of  the  stomach  thus  narrowed  sometimes  does  not  exceed  that 
of  the  intestine.  This  condition  has  been  referred  to  in  the  chapter 
on  Hypertrophic  Gastritis.  When  the  upper  digestive  paths  are  open, 
attacks  of  emesis  occur,  appearing  as  soon  as  the  quantity  of  food 
exceeds  the  very  small  volume  of  the  stomach,  the  small  caliber  be- 
coming still  more  evident  when  one  comes  to  distending  it  with  car- 
bonic acid  or  to  expanding  it  with  the  intragastric  rubber  bag.  If 
stenosis  of  the  esophagus  or  of  the  cardia  exists,  the  passage  of  the 
tube  becomes  impossible,  and  the  symptoms  of  these  constrictions 
assume  enough  importance  to  obscure  entirely  those  which  might  be 
produced  by  the  state  of  the  stomach. 

The  Hour-glass  Stomach. — This  type  of  deformed  stomach  may  be: 


PLATE  XV. 


Adhesions,  Causing  Motor  Insufficiency  but  Retaining  Stomach  in  Normal 

Position. 

S.  Stomach.  L.  Liver.  B.  Gall-bladder.  C,  C,  C.  Colon.  Adhesions  of  stomach 
to  liver  and  gall-bladder  (a^)  and  transverse  colon  («*).  Adhesions  of  hepatic 
flexure  of  colon  to  abdominal  wall  {a^ ,  a^).  Adhesions  of  transverse  colon  to  de- 
scending colon  {a^,  a^)  and  of  descending  colon  to  abdominal  wall  (a^).  Adhesion 
of  hepatic  flexure  to  liver  («^).  The  small  intestine  has  been  dissected  away,  only 
the  mesentery  remaining.  The  end  of  the  ilium  is  visible  in  the  lower  left-hand 
corner. — (^Froin  Attlhor''s  Clinic.) 


the;  hour-glass  stomach.  643 

(i)  Congenital;  (2)  due  to  extensive  cicatrization  of  a  peptic  ulcer; 

(3)  due  to  cancer,  especially  to  scirrhus;  (4)  due  to  an  intense, 
spastic,  and  permanent  contraction  at  the  site  of  the  preantral  sphinc- 
ter; (5)  due  to  peritoneal  adhesions ;  (6)  due  to  abdominal  tumors; 
(7)  due  to  twisting  of  the  stomach;  (8)  due  to  hernia  of  stomach 
through  the  mesocolon.  Stoker  {I.  c.)  has  published  one  case  in  which 
the  stomach  was  divided  into  two  parts  by  a  congenital  furrow,  and 
had  never,  during  life,  presented  any  functional  disturbance.  lago 
(/.  c.)  has  related  the  story  of  a  patient  who  succumbed  when  forty- 
two  years  old,  after  having  suffered  for  ten  months  from  uncontrolla- 
ble vomitings ;  on  the  examination  of  the  abdomen,  a  soft  tumor  was 
found  underneath  the  liver  which  had  been  taken  for  a  displaced  right 
kidney ;  no  tumor  existed  at  the  pylorus ;  emesis  took  place  without 
pain,  and  was  not  preceded  by  regurgitation ;  there  was  no  cachexia. 
At  the  autopsy  the  stomach  presented  two  dilated  sacs,  which  com- 
municated by  a  closed  narrow  passage,  situated  about  the  middle  of 
the  organ;  the  index-finger  could  not  pass  this  constriction.  The 
cicatrices  that  had  produced  this  deformity  had  been  caused  by  a 
former  disease,  which  appeared  at  the  age  of  thirty  and  was  charac- 
terized by  hematemesis  and  acute  pains.  A  patient  fifty  years  old, 
observed  by  Luigi  Mazotti  (/.  c),  experienced  such  intense  pains  after 
meals  that  she  would  squirm  on  her  bed,  and  only  found  relief  after 
having  vomited  everything  that  she  had  just  taken.  At  the  autopsy 
the  stomach  was  found  divided  into  two  parts — the  upper  one  verti- 
cal, the  lower  one  directed  horizontally  toward  the  right  side ;  a  nar- 
row passage  was  situated  between  the  two  parts.  The  lower  portion 
of  the  stomach  had  made  a  complete  circle,  and  the  contracted  point 
was  exactly  the  center  around  which  this  rotation  had  occurred. 
The  upper  part  of  the  stomach  was  distended  by  gases ;  the  lower  part 
was  empty  and  joined  to  the  abdominal  wall  by  adhesions.  When 
the  viscus  had  been  replaced  in  its  normal  position,  it  was  found  that 
neither  the  orifices  nor  the  wall  presented  any  modification,  and  it 
was  impossible  to  discover  the  cause  of  this  displacement.  Two 
cases  of  (i)   Bourget,  (2)  one  of  Schmid  Monard,  (3)  one  of  Jaworski, 

(4)  one  of  Bouveret,  and  (5)  one  of  Watson  Cheyne  were  diagnosed 
intra  vitam.  The  most  practical  methods  for  such  diagnosis  are  dis- 
tention with  air  or  CO2,  gastrodiaphany,  and  the  introduction  of  a 
sound,  or,  better,  of  the  spiral  sound  of  Kuhn  or  Wegele.  The  cases 
numbered  2,  4,  and  5  were  cured  by  operation;  the  others  improved 
under  medical  treatment.     In  another  case,  Chiari  (/.  c.)  suspected 

43 


644  MOTOR   INSUFFICIEJNCY. 

a  cancerous  constriction  of  the  pylorus  in  a  patient  who,  in  reality, 
had  an  intussusception  of  the  stomach  into  the  duodenum. 

Further  particulars  concerning  similar  cases  can  be  found  in  the 
recent  memoirs  of  Bettman  (/.  c),  Bauermeister  {I.  c),  and  Saundby 
(I.  c),  and  in  the  theses  of  Kern  (Inaug. -Dissert.,  Berlin,  1881),  Chiari 
("Wien.  med.  Wochenschr.,"  No.  42,  1890),  von  Hacker,  in  his  mono- 
graph ("Magenoperationen,"  etc.,  published  by  Braumiiller,  Vienna) 
gives  a  number  of  illustrations  of  stomachs  divided  into  three  parts 
by  cicatrices  or  adhesions.     (See  Bibliography  at  end  of  this  chapter.) 

Treatment  of  Motor  Insufficiency  of  the  First  Degree  {Gastric 
Atony  or  Myasthenia). — Prophylaxis. — The  muscularis  of  the  diges- 
tive organs  may  be  weak  by  inheritance.  Chlorosis,  anemia,  tuber- 
culosis and  cholelithiasis,  exhausting  hemorrhages,  infectious  dis- 
eases, typhoid,  malaria,  diphtheria,  influenza,  may  bring  on  myas- 
thenia; and  frequent  and  rapidly  consecutive  childbirths  may,  by 
causing  increase  of  space  in  the  abdominal  cavity  and  loss  of  tone  of 
the  abdominal  muscles,  lead  up  to  gastric  atony.  Insufficient  masti- 
cation, hasty  eating  and  deglutition,  and  defective  teeth  predispose 
to  atony.  The  treatment  in  all  cases  must  seek  the  cause  and  adapt 
itself  to  its  removal.  Anemia  must  be  treated  by  proper  food,  iron, 
extract  of  bone-marrow,  and,  in  proper  cases,  arsenic.  In  women 
with  gastroptosis  and  atony,  the  abdominal  muscles  must  be  strength- 
ened and  supported  by  proper  bandages.  The  treatment  proper 
includes  diet,  hydropathic  and  electrical  procedures,  massage,  and 
medicines. 

Diet. — Patients  with  gastric  atony  may  pursue  one  of  two  courses 
with  regard  to  diet :  either  they  may  eat  frequently,  but  very  little 
at  a  time,  or  they  may  limit  themselves  to  two  meals, — breakfast  and 
dinner, — at  8  a.m.  and  3  p.m.  respectively,  and  permit  the  stomach 
to  rest  after  dinner  until  the  next  morning.  It  can  not  be  determined 
a  priori  which  plan  will  give  the  best  results,  but  for  most  cases  the 
plan  that  secures  most  rest  to  the  overworked  organ  is  the  most  effi- 
cacious. Exclusive  rectal  feeding  for  three  weeks  has  been  followed 
by  very  good  results.  As  water  is  not  absorbed  from  the  stomach, 
the  quantity  of  liquids  must  not  exceed  from  i  to  i  ^  quarts  in  twenty- 
four  hours,  including  all  drinks,  coffee,  soups,  etc.  When  there  is 
a  craving  for  more  liquids  than  this,  they  should  be  introduced  by 
enema. 

My  experience  with  the  frequent  and  persistent  administration  of 
milk,  as  observed  in  milk-cure  sanatoriums  in  Germany,  is  discourag- 


TREATMENT  OE  MOTOR  INSUFFICIENCY.  645 

ing.  I  believe  this  treatment  to  be  a  useless  dietetic  experiment  in 
gastric  atony,  since  the  weight  of  the  milk,  used  in  such  abundance, 
inevitably  overdistends  the  organ. 

The  special  diet  must  be  selected  according  to  the  state  of  the  gas- 
tric secretions.  If  there  is  h3^peracidity,  a  generous  beef  and  mutton 
diet,  with  limited  carbohydrates,  hard-  and  soft-boiled  eggs,  ham, 
tongue,  oysters,  duck,  and  deer  in  a  finely  divided  form,  is  recom- 
mended; of  vegetables,  carrots,  spinach,  soft-boiled  turnips,  beans, 
peas,  and  cauliflower,  all  finely  cut  up  or  as  purees,  are  allowed. 
Potato,  macaroni,  rice,  and  farina  gruel  are  permissible.  If  the 
h^'peracidity  is  the  cause  of  the  atony,  I  favor  restriction  of  proteid 
diet  and  a  preponderance  of  amylaceous  food,  according  to  principles 
laid  down  elsewhere.  Strictness  should  be  observed  concerning  the 
use  of  alcohol,  and  when  a  trial  proves  that  it  injures  digestion,  I 
generally  forbid  claret,  Rhine  wine,  and  even  beer.  But  when  a  trial 
with  light  wines  demonstrates  their  beneficial  action,  about  two 
ounces  of  wine  with  each  meal  may  be  permitted.  Whenever  the 
hydrochloric  acid  is  diminished,  the  lighter  meat  varieties, — chicken, 
pigeon,  birds, — fish,  and  boiled  sweetbreads  or  calves'  brains,  should 
be  allowed  only ;  but  a  larger  amount  of  carbohydrates  may  be  con- 
ceded. The  special  diet  is  stated  more  explicitly  in  the  chapter  on 
Dietetics. 

Constipation  is  a  serious  and  a  constant  accompaniment  of  gastric 
atony;  it  must,  therefore,  receive  our  undivided  attention.  Purga- 
tives should  be  used  only  as  a  last  resort,  and  the  main  reliance  should 
be  placed  on  diet,  massage,  and  electricity.  A  pint  of  cold  water, 
preferably  Bedford  magnesia  spring-water,  in  the  morning  on  an 
empty  stomach,  black  (rye)  or  Graham  bread,  abundance  of  vege- 
tables,— turnips,  carrots,  asparagus,  tomatoes,  rhubarb  plant,  beans, 
peas,  lentils, — noodles,  macaroni,  barley,  sweet  compotes,  plums, 
figs,  apples,  currants,  cranberries,  cider,  buttermilk,  kefyr,  sour  milk, 
honey.  Figs,  plums,  and  senna  leaves  stewed  under  constant  stirring 
until  intimately  mixed,  with  sugar  and  lemon-juice  added,  is  a  use- 
ful laxative.  When  sweetening  is  desired,  milk-sugar  should  be  pre- 
ferred to  cane-sugar.  The  use  of  these  articles  very  rarely  fails  to 
bring  about  regular  evacuations  without  medicines  when  massage 
and  electricity  are  used  in  conjunction.  Whenever  drugs  are  posi- 
tively unavoidable,  I  prefer  cascara  sagrada  or  aloes.  In  pronounced 
atony  constipation  can  not  be  treated  by  this  diet  alone,  because  it 
increases  the  weight  of  the  ingesta. 


646  .  MOTOR   INSUFFICIENCY. 

The  hydropathic  treatment  consists  in  cold  morning  sponge  baths, 
cold  wet-packs,  and  Priessnitz  bandages  to  epigastrium.  In  severe 
neurasthenic  myasthenia  I  am  in  the  habit  of  ordering  a  daily  bath 
containing  three  per  cent,  of  chlorid  of  sodium  and  two  per  cent,  of 
sodium  bicarbonate;  temperature  of  bath,  98°  F. ;  the  patient  should 
remain  in  twenty  minutes.  AA'hen  taken  in  the  evening,  this  bath 
favors  sleep. 

Electric  Treatment. — Intragastric  application  with  the  Einhom 
electrode  within  the  stomach  is  most  effective;  the  faradic  current 
is  applied  up  and  down  over  the  spinal  column  and  over  the  abdomi- 
nal muscles.  The  constant  current  is  applied  in  the  same  manner, 
in  the  strength  of  20  milliamperes  and  for  about  ten  minutes.  Sys- 
tematic massage,  both  general  and  local,  over  the  stomach  is  an 
important  adjuvant. 

Medicinal. — This  form  of  treatment  should  be  as  limited  as  possi- 
ble.    The  most  approved  tonic  for  the  motor  function  is  str\-chnin : 

U.     Strychnin,  sulphatis, 0.021  gm.  gr.  ]^ 

Elixir  gentianae, iSo.o      c.c.  ^vj.  M. 

SiG. — One  tablespoonful  three  times  daily. 

In  anemia  the  gentian  elixir  with  chlorid  of  iron  may  be  substituted. 
When  the  hydrochloric  acid  is  deficient,  it  must  be  supplied ;  when 
it  is  excessive,  it  must  be  neutralized  by  the  following : 

R.     Magnes.  ust. , 15.0  ^ss 

Bismuth  carbonate, 

Natron,  bicarbonat., aa     5.0  ^j  -j- gr.  xv 

Strychnin,  sulphatis, o.l  gr.  iss.         M. 

SiG. — One-half  teaspoonful  one  hour  after  meals. 

Creasote  and  orexin  are  claimed  by  competent  authorities  (Pick 
and  Penzoldt)  to  be  able  to  excite  the  peristalsis ;  the  latter  may  be 
used  when  there  is  anacidity  or  subacidit}'.  Creasote,  in  my  expe- 
rience, does  not  increase  gastric  peristalsis. 

Lavage. — As  a  rule,  one  will  be  able  to  get  along  without  lavage 
in  the  first  stage  of  motor  insufficiency.  But  when  the  food  remained 
in  persistently  overtime,  I  have  seen  improvement  of  muscular  ton- 
icity follow  the  rapidly  alternating  cold  and  warm  intragastric  douche. 
This  exerts  a  powerful  and  stimulating  effect  also  on  the  secretion, 
when  it  is  defective ;  when  the  latter  is  excessive,  the  douching  should, 
be  carried  out  with  alkaline  water. 

Treatment  of  Motor  Insufficiency  of  the  Second  Degree  {Fully 


TREATMENT  OF  MOTOR  INSUFFICIENCY.  647 

Developed  Dilation). — This  maybe  considered  under  three  headings: 
(i)   Dietetic,  (2)  medicinal,  (3)  surgical. 

The  diet  is  essentially  based  on  the  same  principles  as  in  simple 
myasthenia ;  the  amount  of  liquid  permissible  must  not  exceed  1 500 
c.c.  in  twenty-four  hours.  With  exaggerated  vomiting  and  pains, 
exclusive  feeding  by  the  rectum  for  fourteen  days  is  recommended. 
A  specified  diet-list  for  both  simple  atony  and  pronounced  dilation 
will  be  found  on  pages  237  to  239.  It  is  impossible  to  treat  the  latter 
form  successfully  without  lavage;  this  is  not  only  a  palliative  measure 
of  great  value,  but  in  cases  of  atonic  dilatation  due  to  muscular  weak- 
ness, and  not  dependent  upon  mechanical  obstruction,  it  may  even  be 
able  to  effect  a  cure,  when  combined  with  other  means  presently  to 
be  described. 

The  first  washings  are  done  with  pure  warm  water,  but  the  last 
washings  are  done  with  solutions  adapted  to  the  chemical  and  septic 
states  prevalent  in  the  organ.  For  instance,  if  there  are  great  excess 
of  hydrochloric  acid  or  fermentation  by  sarcinae  and  yeast,  sodium 
biborate  or  bicarbonate  should  be  added,  as  these  salts  are  not  only 
antacid,  but,  with  regard  to  these  organisms,  are  also  antiseptic.  If 
there  is  butyric  or  lactic  acid  fermentation,  boric  acid  (3  per  cent.), 
salicylic  acid  (3  per  cent.),  or  creolin  or  lysol  (10  to  15  drops  to  a  quart 
should  be  used ;  but  the  stagnation  can  not  be  prevented  from  recur- 
ring by  these  means  unless  the  motility  is  improved  by  other  treat- 
ment. 

Electricity  is  indispensable :  its  method  of  employment,  internally 
and  externally,  has  been  described  in  a  previous  chapter. 

Massage  undoubtedly  improves  the  gastric  musculature,  but 
should  be  used  only  on  days  when  the  stomach  has  been  washed  out, 
because  the  mechanical  compression  may  force  stagnating  masses 
into  the  intestines,  thus  spreading  the  putrefaction.  Abdominal 
bandages  properly  adapted  and  applied  have  proved  a  valuable  pallia- 
tive measure.  Hydr other apeutic  applications  are  indispensable,  and 
should  be  used  as  described  in  the  paragraph  devoted  to  the  consid- 
eration of  that  treatment. 

Medicinal  treatment  has  a  twofold  object :  (i)  To  promote  the  motor 
function;  (2)  to  prevent,  as  far  as  possible,  gastric  fermentation  and 
decomposition.  The  only  drug  in  which  I  have  any  faith  for  im- 
proving gastric  peristalsis  is  strychnin  sulphate;  it  should  be  given 
in  heavy  doses,  not  less  than  -^-^  of  a  grain  for  adults,  t.  i.  d. 


648  MOTOR   INSUFFICIENCY. 

Boas  combines  strychnin  with  an  antifermentative  in  the  following 
manner : 

R .      Strychnin,  sulphatis, 0.0022  gm.  gr.  -^-^ 

Codein.  phosphoric, 0.03        "  gr.  -f 

Bismuth,  salicylici  (basic), 0.5           "  gr.  viiss.      M. 

SiG. — One  powder  taken  after  each  meal. 

F.  Kuhn  has  proposed  salicylic  acid  (0.5  gm.  to  a  dose),  salicylate 
of  sodium  (15  to  50  grains),  or  saccharin  and  sodium  benzoate  (of 
each,  from  10  to  30  grains  to  a  dose)  to  counteract  gastric  fermenta- 
tion. Carbolic  acid  was  first  used  by  Naunyn  for  the  same  purpose. 
When  there  is  marked  lactic  or  butyric  acid  fermentation,  there  is 
not  a  better  agent  than  hydrochloric  acid  to  counteract  it :  20  to  30 
drops  of  the  dilute  form  in  2  ounces  of  water,  through  a  glass  tube,  or 
in  a  large  gelatin  capsule  of  extra  thickness  (Aaron  capsules).  Among 
other  remedies  that  are  recommended  are:  Salol,  naphthol,  beta- 
naphthol,  beta-naphthol  bismuth,  beta-naphthol  benzoate,  or  benzo- 
naphthol,  hydrochloric  and  carbolic  acid.  Bouchard  is  very  enthu- 
siastic concerning  antifermentative  treatment  of  gastrectasia,  but 
it  is  certain  that  this  treatment  alone,  without  lavage  and  proper 
diet,  is  fallacious. 

Dujardin-Beaumetz  employs: 

R.     Bismuth,  salicyl., 

Magnes.  ustae, 

Sod.  bicarb., aa  lo.o  gm.     gr.  cl.  M. 

SiG. — To  be  divided  into  30  powders ;  one  powder  after  meals. 

Our  formula  for  gastric  fermentation,  particularly  when  asso- 
ciated with  putrid  diarrhea,  is : 

R.     Beta-naphthol  benzoatis,  .    .8  ^ij 

Bismuth,  salicylatis, .    ...  8  ^ij 

Magnesiae  ustse, 8  gij 

Saccharin, .0.5  gr.  viiss 

Menthol, i.o  gr.  xvj.  M. 

SiG. — To  be  divided  either  into  12,  24,  or  36  powders,  to  suit  the  indications  ;  if 
there  is  much  fermentation,  it  should  be  divided  into  12  powders,  and  one  given  three 
times  daily.  Otherwise  it  should  be  divided  into  24  powders,  and  one  given  every  three 
hours. 

Ewald's  formula  for  prevention  of  gastric  fermentation  is  the  fol- 
lowing : 

R.     Resorcin.  resublim.,  .    .    .     5.0  gr.  Ixxv 

Bismuth,  salicyl., 

Pulv.  rad.  rhei, 

Natrii  sulphur.,    .    .    .     aa  lO.O  gr.  cl,  about  3;  iiss 

Sacch.  lact.,    ......  15.0  gr.  ccxxv,  about  J^iij  -{-  ^ij.       M. 

SiG. — Make  a  powder;   one-half  teaspoonful  twice  daily. 


SURGICAL    TREATMENT    OF    MOTOR    INSUFFICIENCY.  649 

When  HCl  secretion  is  lost,  dilute  HCl  should  be  administered, 
according  to  the  formula  given  on  page  475 ;  if  HCl  is  not  well  toler- 
ated, pancreatin  should  be  tried,  according  to  the  principles  given  on 
page  345. 

For  improving  the  appetite,  strychnin,  orexin,  HCl,  and  lavage 
are  the  most  approved  means  of  therapy. 

For  vomiting,  lavage  is  the  most  efficacious  treatment;  but  if  it 
fails,  resorcin  (2  grains  in  ^  of  an  ounce  of  chloroform  water),  or  a 
hypodermic  injection  of  morphin  (^  of  a  grain),  and  atropin  sulphate 
(tto  o^  ^  grain),  will  be  called  for.  Minute  doses  of  calomel  (-^^  of  a 
grain)  every  hour  act  as  gastric  sedatives  in  some  cases.  As  a  rule, 
menthol  and  chloroform  do  not  disappoint  when  used  for  the  relief 
of  vomiting.     The  following  formula  is  practical : 

R.     Menthol, i.o  gr-  xvj 

Chloroform, 1. 5  gtt.  xxiv 

Elixir  simplic, q.  s.    60.0  f^ij-            M. 

SiG. — f^ij  every  hour. 

Insomnia  must  sometimes  be  treated,  as  these  patients  impera- 
tively need  rest ;  for  this  purpose  chloral,  1 5  grains  by  enema,  is  most 
advisable.  Correction  of  hyperacidity  will  often  induce  sleep.  Sul- 
phonal  and  chloral  combined,  eight  grains  of  each,  will  produce  a 
more  lasting  sleep  than  if  either  is  used  alone.  Trional  is  recom- 
mended for  the  same  purpose  by  Boas. 

Surgical  Treatment. — The  operations  that  have  been  suggested  for 
the  relief  of  motor  insufficiency  vary  according  to  the  object  to  be 
accomplished.  Motor  insufficiency  from  simple  atonic  dilatation 
may  be  relieved  by  reducing  the  size  of  the  stomach  by  gastroplica- 
tion  or  gastrorrhaphy  (Weir).* 

If  the  pylorus  is  stenosed  by  a  simple  cicatrix  or  a  hyperplastic 
sphincter,  Loreta's  digital  divulsion  of  the  pylorus  is  an  operation 
that,  judging  from  the  statistics,  is  an  unsafe  and  unreliable  pro- 
cedure. The  pyloroplastic  operation  of  von  Heineke-Mikulicz,  which 
Boas  terms  the  ideal  surgery  for  the  relief  of  pyloric  stenosis  of  a 
benign  nature,  produces  more  permanent  results. 

*  In  June,  1899,  Dr.  Randolph  Winslow  operated  on  a  well-known  Baltimore  phy- 
sician who  had  an  enormous  gastrectasia  and  a  kidney  that  could  be  moved  about  a^ 
libittim  on  the  right  side.  The  doctor,  although  sixty-four  years  old,  submitted  to  opera- 
tion by  my  advice.  The  stomach  was  reduced  by  four  plaits  extending  from  cardia 
to  pyloric  antrum,  and,  at  the  sarrie  time,  a  nephrorrhaphy  executed.  He  made  a  perfect 
recovery,  was  doing  well  on  December  i6th,  1899,  and,  in  his  own  W9rds,  was  "just 
beginning  to  enjoy  life." 


650  MOTOR   INSUI^iflCIENCY. 

Gastro-enterostomy  and  resection  of  the  pylorus,  as  well  as  gastror- 
rhaphy, — an  operation  originated  by  Dr.  Heinrich  Bircher,  a  Swiss 
surgeon, — will  come  under  consideration.  The  indications  for  these 
operations  and  their  technic,  are  subjects  concerning  which  the  reader 
must  be  referred  to  the  chapter  on  Gastric  Surgery.  The  larger  por- 
tion of  dilatations  are  undoubtedly  due  to  some  obstacle  to  the  exit  of 
the  chyme  (ischochymia,  as  Einhorn  calls  it),  and  it  is  rational  to 
presume  that  purely  medical  means  can  not  effect  a  permanent  cure 
of  these  conditioi;s.  But  the  obstructions  or  obstacles  to  the  chyme 
are  not  all  found  in  the  stomach  itself,  for  in  the  account  given  under 
the  etiology,  distended  gall-bladder,  gall-stones  impacted  in  the 
diverticulum  of  Vater,  floating  kidney,  duodenal  cicatrices  and  neo- 
plasm, peritoneal  adhesions,  etc.,  have  been  referred  to,  and  all  of 
these  give  their  separate  and  distinct  indications  for  operation. 

DIET  FOR  MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE 
—ATONY— MYASTHENIA.— (^^«j.) 

Calories. 

8  A,  M. — 100  gm.  of  milk,  50  gm.  of  toast,  30  gm,  of  buUer, 401.2 

10  A.  M. — 50  gm.  of  wheat  bread,  30  gm.  of  butter,  60  gm.  of  scraped  beef,  415.2 
12  M. — 150  gm.  of  boiled  beef,  50  gm.  of  potato  puree  or  macaroni,  .  .  .  439.3 
3  P.M. — 100  gm.  of  milk,  50  gm.  of  Zwieback 401.2 

7  p.  M. — 100  gm.  of  cold  ham  or  beef,  150  gm.  of  wheat  bread,  30  gm. 

of  butter 557.5 

Total,  2214.4 

About  three  ounces  of  good  port  wine  or  claret  may  be  allowed 
during  the  day. 

DIET  -FOR  MOTOR  INSUFFICIENCY'  OF  THE  SECOND  DEGREE 
—PYLORIC  STENOSIS— MYASTHENIC  DILATION.— (^«;m^/-fr.) 

Calories. 

8  A.  M. — 100  gm.  of  Mosquera's  beef  chocolate  or  Somatose  chocolate, 

or  50  gm.  of  tea  with  50  gm.  of  milk  (sweetened  with  saccharin, 

no  sugar),  50  gm.  of  toast, I95*5 

10  A.  M. — 100  gm.  of  scraped  lean  beef, 437 -o 

30  gm.  of  toast, 77.7 

10  gm.  of  butter, 71.3 

Total,  586.0 

12  M. — 150  gm.  of  roast  beef 320.7 

50  gm.  of  potato  puree, 63.7 

Total,  384.4 

In  place  of  the  potato  puree,  the  same  quantity  of  spinach,  car- 
rots, peas,  or  beans  may  be  allowed  as  above. 


OBSTRUCTION    OF    THE    ORIFICES.  65 1 

Diet  for  Motor  Insufficiency  of  the  Second  Degree. — {Continued.') 

Calories. 

2  P.M. — 50  gm.  of  cream, 107.30 

4  P.  M. — 100  gm.  of  tea  or  coffee  with  milk  (no  sugar,  but  saccharin),  50 

gm.  of  toast, 195-50 

7  P.M. — 100  gm.  of  broiled  fresh  fish  or  oysters 71-75 

50  gm.  of  wheat  bread, 129.00 

10  gm.  of  butter, 7i-30 

100  gm.  of  cream, 214.00 

9  P.M. — 50  gm.  of  cream, 162.30 

Total,  1885.15 

In  atony  and  dilation,  as  well  as  in  carcinoma,  experience  is  the 
best  guide  for  enlarging  and  varying  the  diet.  Every  new  article  of 
diet  must  at  first  be  tried  with  great  caution ;  if  liquids  are  well  toler- 
ated, they  may  be  increased,  and  soups  may  be  allowed  for  the  noon 
meal.  The  daily  lavage  should  at  times  be  undertaken  at  hours  when 
a  test-meal  can  be  secured  thereby,  which  will  incidentally  instruct 
the  physician  concerning  the  digestibility  of  new  foods  and,  what  is 
more  important,  the  state  of  the  motor  function. 


OBSTRUCTION  OF  THE  ORIFICES. 
Obstruction  of  the  cardia  and  of  the  pylorus  may  be  organic  or 
functional.  The  former  is,  as  a  rule,  caused  by  the  consequences  of 
carcinoma,  peptic  ulcer,  phlegmonous  or  toxic  gastritis.  The  func- 
tional obstructions  are  due  to  cardiospasm  and  pylofospasm.  These 
conditions  have  all  received  proper  consideration  in  other  chapters. 
There  are  other  very  rare  causes,  which  merit  attention  more  from  a 
pathological  than  from  a  clinical  standpoint. 

Obstruction  of  the  Cardia. 
In  considering  the  organic  causes  which  most  frequently  lead  up  to 
stenosis  of  the  cardia,  it  will  be  important  to  compare  the  table  that 
gives  the  situation  in  the  stomach  of  793  gastric  ulcers  (p.  496)  with 
the  table  on  page  546,  giving  the  situation  in  the  stomach  of  1300 
cases  of  carcinoma.  Thus  it  will  be  found  that  the  pylorus  is  affected 
in  gastric  ulcer  in  12  per  cent,  of  the  cases,  and  the  cardia  in  6.3  per 
cent,  of  the  cases,  making  the  total  percentage  of  involvement  of  the 
orifices  by- gastric  ulcer  18.3  per  cent.  In  carcinoma  the  pylorus  is 
affected  in  60.8  per  cent.,  and  the  cardia  in  8  per  cent.,  of  all  the  cases. 
The  orifices  being,  therefore,  involved  by  carcinoma  in  68.8  per  cent. 


652  MOTOR   INSUFFICIENCY. 

of  all  the  cases.  The  greater  frequency  of  malignant  neoplasm  as  a 
cause  of  stenosis  of  the  orifices  is  evident  from  these  figures.  The 
obstruction  of  the  cardia  may  be  classified  under  the  following  types : 

1.  Congenital  Stenosis. — Like  congenital  stenosis  of  the  pylorus, 
this  is  a  rare  disease,  and  may  be  partial  or  complete.  If  the  stenosis 
is  absolute,  the  child  will  die  very  shortly  after  birth  from  inanition. 
In  partial  congenital  stenosis  of  the  cardia  it  will  be  impossible  for 
solid  food  to  pass,  but  as  the  infant  lives  exclusively  upon  milk,  the 
condition  may  exist  for  a  long  time  without  threatening  life.  I  have 
seen  one  undoubted  case  of  congenital  stenosis  of  the  cardia  in  a  child 
six  years  old  in  which,  after  careful  examination  of  the  esophagus  and 
stomach,  the  symptoms  of  dysphagia  could  not  be  explained  in  any 
other  way.  This  child  has  been  permanently  relieved  by  gradual 
dilatation  of  the  cardiac  ring.  Two  years  have  elapsed,  and  the  child 
remains  well. 

2.  Stenosis  Due  to  Compression. — These  are  brought  about  by  the 
pressure  of  disease  or  dislocated  neighboring  organs — for  instance, 
aortic  aneurysm,  tuberculous  or  syphilitic  mediastinal  lymph-glands, 
neoplasm  of  the  pleura  and  lungs,  diverticulum  of  the  esophagus. 

3.  Obturation  stenosis,  due  to  occlusion  of  the  lumen  by  the  most 
varied  kind  of  foreign  bodies — artificial  teeth,  coins,  ingesta,  masses 
of  the  thrush  fungus ;  by  polypi  which,  arising  from  the  wall  of  the 
pharynx  or  esophagus,  may  extend  down  into  the  lumen  of  the  cardia ; 
protrusion  of  a  portion  of  the  mucosa  of  the  esophagus,  as  in  phleg- 
monous esophagitis  or  abscess  of  the  cardia  or  lower  end  of  the 
esophagus. 

4.  Stenosis  caused  by  cicatrices,  resulting  from  gastric  ulcer,  phleg- 
monous or  toxic  gastritis,  corrosive  destruction  of  the  cardia  by  acids 
or  alkalies  or  other  caustic  materials,  and  in  the  healing  of  syphilitic 
neoplasms  and  ulcers. 

5.  Carcinomatous  Strictures. — These  compose  from  90  to  95  per 
cent,  of  stenoses  of  the  cardia. 

6.  Cardiospasm,  causing  spastic  stenosis  and  cramp  of  the  muscu- 
lature. Stenosis  of  the  cardia  by  simple  hypertrophy  of  the  muscu- 
lar layer  is  unknown.  This  condition  occurs  frequently  enough  in  the 
neighborhood  of  the  pylorus  to  merit  its  consideration  in  a  special 
chapter.  Stenosis  of  the  cardia  has  been  known  to  occur  in  the 
sequence  of  compression  of  the  lower  end  of  the  esophagus,  caused  by 
pericardial  exudates,  cardiac  hypertrophy,  curvature  of  the  spine, 
aneurysm  of  the  aorta.     When  the  lower  end  of  the  esophagus  is 


DIAGNOSIS    OF    STENOSIS    OF    THE    CARDIA.  653 

compressed  only  on  one  side  by  any  one  of  the  conditions  enumerated, 
this  tube  may  escape  to  one  side  and  thereby  avoid  complete  occlu- 
sion; but  when  it  is  compressed  from  several  or  all  sides,  absolute 
stricture  may  result.  When  the  cause  of  the  trouble  is  in  the  imme- 
diate neighborhood  of  the  foramen  rotundum,  through  which  the 
esophagus  perforates  the  diaphragm,  the  symptoms  may  be  identical 
with  those  of  stenosis  of  the  cardia. 

Symptomatology. — This  has  been  given  under  the  heading  of 
Carcinoma  of  the  Cardia,  page  566.  Suffice  it  to  say  that  the  charac- 
teristic symptom  is  dysphagia.  When  the  stenosis  is  due  to  carci- 
noma, the  dysphagia  may  sometimes  become  temporarily  alleviated. 
This  is  due  to  exulceration  of  the  malignant  tumor.  At  first  only 
solid  food  becomes  arrested  in  the  lower  portion  of  the  esophagus,  but 
later  on  not  even  liquid  food  will  pass  the  constriction.  The  patients 
accurately  locate  the  obstruction  to  swallowing  at  the  level  of  the  en- 
siform  cartilage.  In  the  beginning  of  the  stenosis  repeated  swallow- 
ing will  succeed  in  passing  on  the  morsels  of  food  through  the  constric- 
tion. Careful  chewing  and  thorough  insalivation  facilitate  the  act. 
Sometimes  the  sufferers  seek  relief  by  drinking  water  after  the  solid 
food  or  by  stroking  downward  along  the  front  of  the  throat  and  chest. 
If  solid  food  clogs  up  the  upper  or  middle  third  of  the  esophagus,  the 
signs  of  dyspnea  become  very  intense.  In  the  beginning  of  the 
stenosis  practice  in  swallowing  seems  to  make  the  act  easier.  After 
each  pause,  when  nothing  has  been  swallowed  for  a  long  time,  the  act 
becomes  more  difficult.  The  food  is  regurgitated  after  varying 
periods.'  At  first  it  occurs  only  during  ingestion  or  shortly  afterward, 
but  later  on  a  dilation  develops  above  the  constriction,  and  the  food 
is  retained  longer.  Then  regurgitation  occurs  between  meals.  The 
food  which  is  brought  up  is  usually  covered  with  mucus;  in  carci- 
noma, with  blood  and  mucus,  and  it  is  then  in  a  state  of  putrefaction. 
The  food  is  generally  neutral  or  slightly  alkaline.  Its  chemical  char- 
acter gives  no  evidence  of  its  having  entered  the  stomach.  Blood  in 
the  regurgitated  food  may  come  from  carcinoma,  ulcer,  or  cardio- 
esophageal  veins  in  a  state  of  passive  congestion. 

For  the  physical  signs  of  stenosis  of  the  cardia  see  page  566.  The 
condition  of  appetite  and  thirst  is  variable.  Generally,  the  patients 
complain  of  great  hunger  and  excessive  thirst. 

Diagnosis. — The  physical  inspection  of  the  abdomen  is  suggestive. 
As  no  food  can  pass  the  stenosis,  the  stomach  and  the  intestine  hav- 
ing been  empty  for  a  prolonged  period,  the  abdominal  walls  are  very 


654  MOTOR  INSUFFICIENCY. 

much  retracted  and  sunk  in  beneath  the  level  of  the  costal  arch. 
In  attempting  to  locate  the  stenosis  by  introducing  an  esophageal 
sound,  a  very  soft  instrument  should  at  first  be  used,  in  order  to  avoid 
injury  to  a  possible  esophageal  or  gastric  ulcer  or  carcinoma.  In  the 
chapter  on  the  Technics  of  the  Stomach-tube  we  have  referred  to 
a  case  from  Penzoldt's  clinic,  in  which  the  stomach  should  have  been 
washed  out  in  the  morning,  but,  for  some  reason,  this  was  postponed 
until  the  evening.  On  the  same  afternoon  the  patient  died  of  rup- 
ture of  an  aortic  aneurysm  into  the  esophagus.  Stenosis  of  the  cardia 
might  possibly  be  due  to  an  aortic  aneurysm,  and  sounding  of  the 
esophagus  may  lead  to  rupture  of  the  sac. 

The  constriction  is  generally  located  by  means  of  the  tube  as  being 
about  forty  centimeters  from  the  point  where  the  incisor  teeth  touch 
the  introduced  sound.  This  is  only  an  approximate  figure,  as  the 
length  of  the  esophagus  will  A^ary  with  the  height  of  the  person.  In 
one  case  of  carcinoma  of  the  cardia  in  our  experience,  the  tube  could 
be  introduced  for  fifty  centimeters  before  it  struck  the  stenosis.  (For 
rules  to  determine  the  length  of  the  esophagus  in  any  individual,  see 
Hemmeter,  "New  York  Medical  Journal,"  December  28,  1895,  quoted 
on  p.  1 19  of  this  volume.)  In  case  of  carcinoma  patient  research  will 
eventually  result  in  the  discovery  of  a  fragment  of  the  neoplasm  which 
in  these  cases  is  generally  found  in  the  eye  of  the  tube.  Cardiospasm 
occurs  mainly  in  neuropathic  individuals.  It  differs  from  the  organic 
stenosis  of  the  cardia  from  the  fact  that  the  obstruction  is  not  con- 
stant, but  intermittent.  Large  sounds  will  pass  as  readily  as  small 
ones  after  a  little  practice  in  the  introduction,  and  the  stenosis  will 
disappear  entirely  under  anesthesia. 

Prognosis. — Though  dependent  on  the  fundamental  alteration 
causing  the  stenosis,  it  is  generally  unfavorable,  except  in  cardio- 
spasm. Prognosis  is  absolutely  hopeless  in  carcinoma.  When  the 
stenosis  is  due  to  cicatricial  contraction,  the  orifice  may  remain 
patent  sufficient  to  carry  on  nutrition,  and  for  a  long  time  the  nar- 
rowing process  may  appear  stationars'. 

Treatment. — The  treatment  is,  in  the  main,  the  same  as  for  car- 
cinoma of  the  cardia  {vide).  Nutritive  enemata  are,  in  my  experi- 
ence, best  used  as  soon  as  the  diagnosis  of  obstruction  is  certain,  even 
if  a  limited  amount  of  food  can  be  introduced  through  the  mouth. 
Stenosis  due  to  cicatricial  contraction  can  be  successfully  treated  by 
gradual  dilation  of  the  constriction  by  means  of  sounds  of  greater  and 
greater  thickness. 


TREATMENT   Q-p   STENOSIS   OF   THE   CARDIA.  655 

Sometimes  the  cardiospasm  is  due  to  an  ulcer  that  has  been  heaHng 
very  slowly,  or  possibly  to  a  small  erosion  due  to  the  passing  violence 
of  some  sharp  body  in  the  food.  In  one  case  of  dysphagia,  which  was 
due  to  ulcer  of  the  cardia,  we  relieved  the  pain  and  made  swallowing 
possible  by  a  kind  of  local  treatment.  A  small  sponge,  saturated  with 
a  four  per  cent,  solution  of  cocain,  was  placed  in  the  end  of  a  stomach- 
tube  that  had  only  a  side  opening,  the  lower  end  of  the  tube  being 
bluntly  closed;  when  the  lateral  opening  had  reached  the  stenosis, 
the  cocain  solution  was  pressed  out  by  a  wire  which  terminated  in  a 
small  round  ball  resting  upon  the  sponge,  and  emptied  the  cocain  on 
the  painful  surface. 

Patients  with  stenosis  of  the  cardia  fear  starvation,  and  justly  so. 
The  moral  effect  of  sufficient  nutrition  is  a  great  one.  I  am  in  the 
habit  of  feeding  all  patients  into  whom  a  tube  can  be  passed  at  least 
three  times  daily  with  food  representing  a  caloric  value  beyond  what 
is  really  required.  Benign  strictures  of  the  lower  end  of  the  esopha- 
gus and  of  the  cardia  have  been  cured  by  the  patients  themselves, 
after  they  had  acquired  the  technic  of  sounding  and  dilation.  The 
longer  the  sound  remains  in  position  after  it  has  passed  the  stenosis, 
the  more  effective  will  be  the  widening  process.  Leyden  has  succes- 
sivel}^  employed  permanent  cannulas,  which  remain  in  situ  for  several 
days.  He  has  even  employed  them  in  carcinomatous  constrictions 
in  the  lower  end  of  the  esophagus.  These  cannulas  can  be  introduced 
by  the  aid  of  the  stomach-tube.  They  are  from  six  to  eight  centi- 
meters long,  and  are  attached  by  means  of  strong  cords  to  the  ear  or 
around  the  neck.  The  diet  should  consist  of  raw  eggs,  milk,  thin 
chocolate,  meat  powder,  somatose,  gelatin;  also  ice-cream  and  frozen 
custard  may  be  allowed,  but  must  be  warmed  in  the  mouth  and  eaten 
slowly.  Egg-nog  should  not  contain  too  much  brandy.  Not  much 
should  be  expected  from  medicinal  treatment.  Morphin  or  codein 
can  not  be  avoided  for  the  relief  of  pain.  For  the  pain  of  cancer  of 
the  cardia  we  have  found  chloral  hydrate  (gr.  xv,  t.  i.  d.)  especially 
effective.  lodid  of  potassium  and  sodium,  methylene-blue,  and 
arsenic  have  been  recommended  for  cancerous  stricture.  Personally, 
I  have  no  faith  in  these  medications.  The  iodids  should  be  tried, 
however,  if  there  is  a  suggestion  or  evidence  of  syphilis  about  the  case. 
When  a  dilation  of  the  esophagus  has  formed  above  the  constriction, 
it  is  well  to  wash  out  the  pouch  every  morning,  as  one  would  wash 
out  a  dilated  stomach.  This  will  prevent  a  septic  esophagitis.  The 
mouth,  nose,  and  throat  should  be  kept  disinfected  by  antiseptic 
sprays  and  gargles. 


656  MOTOR   INSUFFICIENCY. 

Gastrostomy  will  prolong  life  if  performed  early  enough.  In  our 
experience  even  if  the  stenosis  is  due  to  a  carcinoma,  it  will  not  pro- 
gress so  rapidly  when  it  is  kept  free  from  food,  and  disinfected  daily 
by  lavage  from  above.  But  when  gastrostomy  is  undertaken  in 
benign  stenosis,  it  not  only  makes  possible  the  proper  feeding  of  the 
patient,  but  the  stenosis  can  be  dilated  after  the  operation  by  intuba- 
tion from  the  gastric  end  of  the  esophagus. 

Exploratory  laparotomy  may  reveal  the  fact,  unknown  before  the 
operation,  that  although  the  stenosis  of  the  cardia  was  due  to  a  carci- 
noma, this  neoplasm  was  sufficiently  below  the  diaphragm  to  be  en- 
tirely removed.  The  recent  success  of  Brigham  and  vSchlatter  after 
a  total  extirpation  of  the  stomach  makes  it  conceivable  that  large 
portions  of  the  cardiac  end  and  fundus  can  be  removed,  and  the  re- 
mainder of  the  healthy  stomach  or  the  jejunum  attached  to  the  stump 
of  the  esophagus.  (See  section  on  Surgical  Treatment  of  Organic 
Diseases.) 

Obstruction  of  the  Pylorus. 
Stenosis  of  the  pylorus  is,  in  the  majority  of  cases,  a  consequence  of 
organic  disease.  Idiopathically  it  occurs  very  rarely  in  children  in 
the  form  of  congenital  atresia.  Meltzer  and  Adler  each  reported  one 
such  case  to  the  meeting  of  the  Association  of  American  Physicians  in 
May,  1898.  Maier  has  collected  thirty-one  cases  of  this  kind  ("Vir- 
chow's  Archiv,"  Bd.  cii).  The  stenosis  due  to  pylorospasm  is  de- 
scribed in  chapter  IX.  The  pylorus  may  become  obstructed  by  a 
swallowed  foreign  body  that  may  become  lodged  in  it,  by  a  gall-stone, 
or  a  gastrolith.  Hypertrophic  pyloric  stenosis  has  been  considered  in 
a  special  chapter.  Obstruction  due  to  benign  tumors  is  exceedingly 
rare;  such  abnormalities  are  not  discovered  except  at  autopsies.  Dr. 
W.  S.  Thayer,  of  the  Johns  Hopkins  Hospital,  has  related  to  the  writer 
a  case  in  his  experience  in  which  obstruction  of  the  pylorus  had  been 
caused  by  a  fibroma.  For  further  information  concerning  benign 
tumors,  foreign  bodies,  gastroliths,  etc.,  the  reader  is  referred  to  chap- 
ter VI,  of  part  III.  vScar  tissue  may  develop  in  the  neighborhood  of 
the  outlet  of  the  stomach  as  a  result  of  the  destructive  action  of  cor- 
rosive poison.  This  is  also  a  rare  occurrence,  since  chemicals  that  are 
swallowed  in  sufficient  quantity  to  destroy  the  pyloric  tissue  would, 
most  probably,  cause  death  by  the  injury  they  inflict  on  the  esopha- 
gus and  portions  of  the  stomach.  The  outlet  of  the  stomach  may  be 
compressed  by  tumors  developing  in  its  vicinity,  such  as  pancreatic 


OBSTRUCTION    OF   THE    PYLORUS.  657 

cysts,  malignant  tumors  of  the  pancreas,  liver,  and  omentum,  fecal 
concretions  in  the  colon.  The  lodgment  of  a  large  gall-stone  in  the 
common  bile-duct  or  in  the  duodenum  has  been  known  to  have  the 
same  effect. 

Perigastritis  and  peritonitis  may  effect  stenosis  of  the  pylorus  by 
constricting  bands  of  fibrous  tissue.  The  author  has  reported  a  case 
of  persistent  gastralgia  in  a  negro,  operated  upon  on  his  advice  by  Dr. 
John  D.  Blake.  The  stomach  was  bound  down  to  the  liver,  dia- 
phragm, and  transverse  colon  by  numerous  adhesions.  Those  going 
to  the  liver  had  produced  an  absolute  stenosis  of  the  pylorus. 

Syphilitic  and  tubercular  ulcers  (see  chapter  devoted  to  this  sub- 
ject) are  very  rare  in  the  stomach.  In  one  case  of  tubercular  ulcera- 
tion extending  through  the  pylorus  into  the  duodenum  the  author 
found  this  orifice  normally  permeable. 

A  number  of  the  causes  enumerated  may  also  bring  about  duodenal 
stenosis  and  obstruction,  which  is  often  clinically  indistinguishable 
from  pyloric  obstruction. 

Peptic  ulcer  may  effect  constriction  of  the  outlet  of  the  stomach  in 
three  ways :  ( i )  The  induration  inflammatory  thickening  of  the  edges 
of  the  ulcer  may  encroach  upon  the  lumen  of  the  pylorus;  (2)  the 
pain  and  irritation  of  the  ulcer  may  cause  pylorospasm ;  (3)  in  healing 
the  contraction  of  the  cicatrix  may  effect  a  deformity  of  the  pyloric 
canal.  The  most  frequent  cause  of  pyloric  obstruction  is  cancer. 
From  the  tables  referred  to  previously,  it  is  evident  that  ulcer  affects 
the  pylorus  in  12  per  cent,  of  793  cases  collected  by  Welch ;  and  carci- 
noma occurred  in  the  pyloric  region  in  60.8  per  cent,  of  1300  cases  of 
cancer  collected  by  the  same  author. 

Symptomatology. — The  symptoms  of  pyloric  stenosis  may  be 
arranged  under  three  headings — compensation,  stagnation,  and  re- 
tention— which  represent  degrees  and  phases  of  the  consequences  of 
the  obstruction.  This  classification  of  the  symptoms  has  been  in- 
geniously followed  out  by  Van  Valzah  and  Nisbet  ("Diseases  of  the 
Stomach,"  p.  584).  Not  all  cases  present  these  three  degrees,  for 
whenever  the  stenosis  is  malignant,  the  stage  of  compensation  does 
not  occur.  The  results  of  stenosis  are  familiar  from  the  analogies 
with  stenosis  of  other  hollow  muscular  organs,  such  as  the  heart  and 
the  bladder.  When  the  pylorus  is  narrowed,  the  stagnating  ingesta 
may  influence  the  musculature  in  two  diagonally  opposite  ways. 
They  may  effect  a  stretching  and  dilatation,  or  constitute  anincentive 
to  the  gastric  musculature  bringing  on  increased  contraction  and  peri- 


658  MOTOR   INSUFFICIENCY. 

staltic  unrest.  The  result  that  will  be  produced  depends  upon  the 
state  of  nutrition  of  the  musculature  at  the  time  the  stenosis  occurs. 
We  exclude  malignant  tumors  as  agents  causing  the  increase  of  gas- 
tric musculature  by  hyperplasia  of  the  normal  tissues.  If  the  gastric 
muscular  fiber  is  well  nourished,  new  formation  of  muscle-fibers  and 
increased  contraction  will  result.  This  constitutes  the  stage  of  com- 
pensation. But  if  they  are  badly  nourished,  a  dilation  of  the  stomach 
will  result,  leading  to  stagnation  and  retention,  so  that  development  of 
dilation  on  one  hand  or  hypertrophy  on  the  other,  depends  largely 
upon  the  state  of  nutrition  of  the  gastric  muscle.  But  if  the  obstruc- 
tion persists,  which  it  does  as  a  rule,  the  distention  of  the  gastric  wall 
and  consequent  permanent  dilation  will  eventually  supervene,  al- 
though compensation  had  been  for  a  time  established.  In  case  the 
constriction  be  moderate  and  remains  so,  and  overburdening  of  the 
gastric  wall  be  carefully  avoided,  a  normal  volume  of  the  hypertrophic 
stomach  will  persist  for  a  long  time.  There  are  three  factors  that 
control  the  advent  of  stagnation  and  retention — (i)  the  width  of  the 
outlet,  (2)  the  bulk  and  weight  of  the  ingesta,  and  (3)  the  neuro- 
muscular energy  of  the  expulsive  force.  Thus,  stagnation  and  reten- 
tionmay be  caused  by  gastric  atony  or  myasthenia,  because  the  expul- 
sive force  is  not  sufficient  to  expel  the  contents.  It  may  occur  after 
excessive  burdening  of  the  stomach  by  ingesta,  because  the  weight 
on  the  gastric  contents  is  too  heavy  for  the  musculature. 

Hyperacidity  and  supersecretion  may  cause  stagnation  and  reten- 
tion of  food  by  producing  a  secondary  pyloric  spasm.  The  tonic  con- 
tractions of  the  pylorus  in  excessive  secretion  of  acid  gastric  juice 
appear  to  be  a  precaution  to  prevent  undue  acidification  of  the  duo- 
denal digestive  juices.  A  small  quantity  of  free  HCl  has  little  or  no 
retarding  influence  on  the  diastatic  action  of  pancreatic  juice  (Rach- 
ford),  but  a  very  acid  gastric  chyme  renders  the  ferments  of  the  pan- 
creatic juice  inoperative.  As  a  rule,  the  dilation  of  the  stomach  is 
secondary  to  the  stenosis ;  but  there  are  very  rare  and  curious  cases 
in  which  the  stenosis  is  caused  by,  and  secondary  to,  the  dilatation. 
(See  chapter  on  Motor  Insufficiency.)  When  distention  and  dilation 
have  been  caused  by  overburdening  the  stomach,  hypertrophy  of  the 
musculature  may  counteract  stagnation  and  retention;  but  if  the 
musculature  is  incapable  of  resistance  of  further  development,  the 
overdistention  of  the  stomach  may  distort  the  lumen  of  the  pylorus, 
producing  a  secondary  stenosis.  I  have  reported  a  number  of  cases 
in  which  the  stomach  was  of  normal  size  when  empty,  but  showed  all 


CONGENITAL   PYLORIC   STENOSIS.  659 

the  evidences  of  dilation  when  filled  with  food.  At  the  operation  a 
rather  sharp  bend  in  the  duodenum  just  beyond  the  pylorus  was  dis- 
covered by  the  author.  The  kinking  of  the  duodenum  was  effected 
by  traction  when  the  stomach  was  overdistended.  Kussmaul 
("Peristalt.  Unruhe  d.  Magens,"  Volkmann's  Vortrage,  Nr.  181)  has 
described  a  similar  condition  in  the  duodenum  produced  secondarily 
by  dilated  stomachs,  and  reproduced  the  abnormality  experimentally 
in  the  cadaver.  Stenosis  of  the  pylorus,  as  far  as  the  relation  between 
(i)  expulsive  power  and  (2)  bulk  of  gastric  chyme  are  concerned, 
may  be  (a)  absolute  or  (b)  relative.  (See  p.  477.)  In  such  condi- 
tions of  secondary  stenosis,  although  the  constriction  may  not  be  ab- 
solute, yet  it  may  be  relative  because  it  may  not  suffice  for  the  exit  of 
the  large  quantity  of  the  gastric  contents ;  or,  again,  even  when  the 
contents  are  not  excessive,  the  width  of  the  outlet  may  be  relatively 
too  small  for  the  contractile  power  of  the  musculature. 

Congenital  Pyloric  Stenosis. — The  subject  of  congenital  hyper- 
trophic stenosis  of  the  pylorus  in  infants  has  been  ably  reviewed  in  an 
article  by  S.  J.  Meltzer  ("New  York  Medical  Record,"  Aug.  20,  1898), 
in  which  he  adds  a  new  case  to  the  literature  of  this  subject.     A  his- 
tological examination  of  the  stomach,  after  the  autopsy,  was  made  by 
T.  Mitchell  Prudden,  showing  the  thickening  of  the  pylorus  to  have 
been  largely  due  to  the  presence  of  dense  fibrous  tissue  in  the  sub- 
mucosa,  and  to  a  hyperplasia  of  the  inner  muscular  layer,  especially 
of  the  proximal  half  of  the  pyloric  portion.     The'  moderate  thickening 
of  the  wall  of  the  gastroduodenal  valve,  which  could  be  seen  as  a 
prominence  when  viewed  from  the  duodenal  side,  was  almost  wholly 
due  to  fibrous  hyperplasia  in  the  submucosa.     At  the  proximal  end 
of  the  pyloric  portion  the  thickening  was  due  to  increase  in  the  sub- 
mucosa and  inner  muscular  layer.     The  external  muscular  layer  pre- 
sented no  abnormality.     I^ike  others  who  have  considered  this  sub- 
ject, Meltzer  divides  the  life-history  of  this  stomach  into  three  phases 
— (i)  the  phase  of  simple  insufficiency,  (2)  of  attempted  compensa- 
tion, and  finally  (3)  the  phase  of  atony  and  dilation.     The  stomach  of 
this  neonatus  when  completely  filled  for  the  first  time  was  not  able 
to  empty  itself  thoroughly  in  the  interval  before  the  second  feeding; 
only  a  part  of  its  contents  could  be  evacuated  into  the  intestines.     A 
portion  remained  behind  in  the  stomach,  and  was  present  there  when 
the  second  feeding  took  place.     This  same  partial  retention  occurring 
with  every  feeding  finally  led  to  overdistention,   which,   in  turn, 
evoked  the  increased  contractility  of  the  muscularis,  followed  by  a 
44 


66o  MOTOR   INSUFFICIENCY. 

somewhat  greater  quantitative  expulsion  of  the  contents  into  the  in- 
testine.    But  as  the  accumulation  of  remnants  in  the  stomach  had 
been   proportionately  greater   before   this   extraordinar}^  muscular 
effort  took  place,  the  balance  remaining  in  the  stomach  was,  notwith- 
standing, greater  now  than  in  the  foregoing  interval.     Finally,  a 
stage  will  come  when  the  muscular  fibers  make  their  extremest  effort 
upon  the  accumulation  of  the  several  balances  in  the  stomach ;  this 
extreme  effort  results  in  the  expulsion  of  the  entire  contents  by  vom- 
iting.    This  stage  is  that  of  insufficiency.     The  stomach  is  unable  to 
empty  its  contents  entirely  into  the  intestine,  but  it  is  not  yet  in  a 
state  of  dilation.     The  muscularis  still  retains  its  tonicity.     The  con- 
stant overdistention  in  the  method  I  have  previously  described  causes 
the  development  of  a  varied  degree  of  muscular  h5^pertrophy,  Vv^hich, 
when  once  accomplished,  causes  the  stomach  to  respond  even  to  mod- 
erate overdistention  with  very  powerful  contraction,  so  that  the  en- 
tire gastric  contents  may  be  expelled  through  the  cardiac  orifice.    The 
frequent  repetition  of  this  form  of  evacuation  may  then  bring  on 
insufficiency  of  the  cardia.     Frequent  vomiting  generally  starts  with 
the  development  of  the  compensating  hypertrophy  of  the  gastric 
muscularis.     The  unnecessarily  strong  contraction  effects  a  partial 
dilation  of  the  pyloric  stenosis  in  a  similar  manner  as  it  overcomes  the 
normal  contraction  of  the  cardia.     It  is  also  instrumental  in  the  ab- 
normal distention  of  the  fundus,  for  in  this  portion  the  muscularis  is 
very  thinly  developed,  and  does  not  take  part  in  the  hypertroph}^ 
that  is  so  prominent  toward  the  pyloric  end.     During  the  powerful 
contraction  of  the  hypertrophied  pyloric  portion  the  gastric  contents 
are  driven  into  the  fundus,  which  is  incapable  of  much  resistance,  and 
gradually  becomes  distended  and  dilated.     As  it  is  impossible  for  the 
contracting  pyloric  portion  to  evacuate  all  of  the  ch3"me,  a  considera- 
ble portion  must  remain  in  the  most  dilatable  portion  of  the  stomach. 
This  is  the  fundus.     As  the  accumulated  balances  of  many  feedings 
become  larger  and  larger,  in  proportion  to  the  increased  size  of  the 
fundus,  the  hypertrophied  pyloric  end  finally  exhausts  itself  in  its 
efforts  to  overcome   the  obstruction :  it   loses  its  contractility,  the 
muscular  fibers  may  become  degenerated  through  overexertion,  and 
eventually  the  third  phase,  that  of  gastrectasis,  is  reached. 

The  body  is  insufficiently  nourished  long  before  this ;  in  the  phase 
of  compensation  it  begins  to  suffer,  and  though  with  the  increased 
pressure  within  the  stomach  a  greater  transmission  of  food  into  the 


DIAGNOSIS   AND   PROGNOSIS.  66 1 

intestine  takes  place,  the  amount  passed  is  inadequate  for  the  nutri- 
tion of  the  body. 

This  detailed  description  of  the  mechanism  of  pyloric  insufficiency 
and  the  consequent  stages  of  compensation  and  dilation  was  consid- 
ered necessary  because  it  represents,  in  rough  outlines,  exactly  what 
occurs  in  ever}'  case  of  pyloric  stenosis,  excepting,  perhaps,  those 
cases  due  to  carcinoma.  Here  the  carcinomatous  invasion  and  the 
consequent  putrefaction  and  gastrectasis  prevent  the  stage  of  com- 
pensation. 

Diagnosis. — In  the  first  stage  the  greediness  which  the  child  dis- 
plays in  taking  the  nursing-bottle  and  the  constant  crying  should 
suggest  the  possibility  of  congenital  stenosis  of  the  pylorus.  A  cathe- 
ter should  be  introduced  into  the  stomach  about  two  hours  after  feed- 
ing, and  the  organ  evacuated.  The  amount  of  the  previous  feeding 
must  be  known.  If  there  is  a  residual  balance  in  the  stomach,  it  is 
evident  that  an  insufficiency  is  present.  In  the  second  stage  Meltzer 
places  reliance  on  the  following  symptoms :  The  change  of  the  area  of 
percussion  with  the  degree  of  filling  of  the  stomach ;  the  appearance 
of  peristaltic  waves  over  the  region  of  the  stomach ;  palpation  of  the 
contracted  stomach  in  an  empty  state.  In  the  stage  of  compensated 
hypertrophy  the  frequent  vomiting  immediately  after  drinking,  the 
absence  of  vomiting  at  any  other  time,  the  absence  of  bile  from  the 
vomit,  and  its  non-catarrhal  appearance  are  characteristic  symptoms. 
The  diagnosis  of  the  last  stage,  the  gastrectasis,  should  offer  no  diffi- 
culty. The  stomach  may  be  filled  with  air  or  water,  when  palpation 
and  percussion  will  give  evidence  of  the  dilation.  When  air  is  blown 
into  the  partly  filled  stomach,  a  gurgling  sound  can  be  localized  at  an 
abnormally  low  level  by  means  of  the  stethoscope.  Simple  inspection 
will  reveal  the  bulging  upper  part  of  the  abdomen,  while  the  lower 
part  is  in  a  collapsed  state.  W.  Soltau  Fenwick  (' '  Disorders  of  Diges- 
tion in  Infancy  and  Childhood")  was  able  to  examine  the  contents  of 
such  an  infant  stomach,  after  a  test-meal,  and  found  that  the  secre- 
tion of  HCl  was  normal. 

Prognosis. — The  disease  usually  proves  fatal  within  the  first  three 
months  of  infant  life,  very  frequently  within  a  few  weeks.  Few  chil- 
dren having  congenital  stenosis  of  the  pylorus  live  to  attain  adult  life. 
It  seems  that  the  disease  is  not  necessarily  fatal  within  itself,  but  be- 
comes so  because  it  is  not  recognized.  With  an  early  diagnosis  and 
proper  treatment  the  lives  of  some  of  these  infants  might  be  saved. 
Four  children  are  on  record  as  having  been  kept  alive  by  these 


662  MOTOR   INSUFFICIENCY. 

means — three   cases    published    by   Heubner    {I.    c.)    and    one   by 
Henschel  {I.  c). 

Treatment. — The  palliative  treatment  consists  in  regulation  of  the 
feeding,  and  frequent  washing  of  the  stomach.  The  advice  of  Melt- 
zer  to  give  a  slightly  larger  amount  of  milk  than  the  normal  capacity 
of  the  stomach  in  the  first  stage  of  the  trouble — in  order  to  bring  out 
better  contraction  of  the  muscular  tissue,  and  drive  more  food  into 
the  intestines,  and  thereby  effect  dilation  of  the  pylorus — seems  to 
me  a  doubtful  procedure.  Overburdening  of  the  gastric  walls  can  do 
nothing  but  harm,  and  the  expected  increase  of  muscular  contraction 
may  not  take  place.  We  can  not  tell  the  condition  of  the  nutrition  of 
the  muscular  layer.  Washing  the  stomach  with  a  one-half  of  a  one 
per  cent,  solution  of  Carlsbad  salts  is  recommended  by  Heubner.  A 
very  small  piece  of  tenacious  mucus  or  a  coagulum  of  milk  sticking 
in  the  pylorus  may  be  sufficient  to  make  this  passage  absolutely  im- 
penetrable. Hence  the  utility  of  lavage.  Massage  of  the  stomach 
has  been  recommended.  Rectal  enemata  of  milk  and  egg-albumen 
will  support  the  strength  of  the  little  patient.  But  the  only  curative 
procedure  is  operation.  There  have  been  cases  when  the  infant  lived 
a  number  of  years  without  operation;  but  in  view  of  the  rapid  ad- 
vances of  gastric  surgery,  and  the  positive  and  permanent  relief  ac- 
cruing from  a  successful  gastro- enterostomy,  operation  should  be 
urged  whenever  the  diagnosis  can  be  clearly  established. 

LITERATURE    ON    CONGENITAL    HYPERTROPHIC    STENOSIS    OF 
THE    PYLORUS    IN    INFANTS. 

1.  Ashby,  H.,  "Archives  of  Pediatrics,"  1897. 

2.  Finkelstein,  "  Jahrbuch  f.  Kinderheilk.,"  vol.  Vlll,  1896,  p.  105. 

3.  Thompson,  "On  Congenital  Gastric  Spasm,"  "The  Scottish  Med.  and 
Surg.  Jour.,"  1897. 

4.  Henschel,  "  Archiv  f.  Kinderheilk.,"  vol.  Xlli,  1891,  p.  32. 

5.  Schwyzer,  "  New  York  Med.  Jour.,"  1897. 

6.  RoIIeston  and  Haynes,  "  British  Med.  Jour.,"  April  23,  1898,  p.  1070. 

7.  Williamson,  "  London  and  Edmburgh  Monthly  Jour,  of  Med.  Sciences," 
1841,  p.  23. 

8.  Davoski,  "  Caspar's  Wochenschrift,"  1842,  No.  7. 

9.  Hirschsprung,  "  Jahrbuch  f.  Kinderheilk.,"  vol.  xxviii,  1888,  p.  61. 

10.  Gran,  "Jahrbuch  f.  Kinderheilk.,"  vol.  xliii,  1896,  p.  118. 

11.  Landerer,  "  Ueber  angeborene  Stenose  des  Pylorus,"  Dissert.,  Tiibingen, 

1879. 

12.  Maier,  Rud.,  "Virchow's  Archiv,"  vol.  cii,  1885,  p.  413. 

13.  Meltzer,  S.  J.,  "  N.  Y.  Med.  Rec,"  Aug.,  1898. 

14.  Huebner,  Quoted  by  Finkelstein. 

15.  Peden,  "  Glasgow  Med.  Jour.,"  1889,  p.  416. 


EFFECTS   OF  VARIOUS   FORMS   OF   STENOSIS.  663 

16.  Pitt,  "Trans.  Path.  Soc,"  London,  1889,  p.  63. 

17.  De  Bruin  Kops,  "  Nederlandsch.  Tijdschrift  voor  Geneeskunde,"  1896, 
No.  19.     (After  Thomson.) 

18.  Thomson,  "  Edin.  Hosp.  Reports,"  vol.  iv,  1896,  p.  116. 

19.  Schwyzer,  "  New  York  Med.  Jour.,"  Nov.  21,  1896. 

20.  Fenwick,  "The  Disorders  of  Digestion  in  Infancy  and  Childhood," 
London,  1897. 

21.  Loesschaft,  "  Jahrbuch  f.  Kinderheilk.,"  vol.  xxii,  p.  164. 

22.  Brandt,  "  Die  Stenose  des  Pylorus,"  Dissert.,  Jena,  1851. 

For  Obstruction  of  the  Pylorus  Caused  by  Cicatrices,  Pep- 
tic Ulcer,  or  Carcinoma,  see  the  chapters  devoted  to  these  sub- 
jects. 

Various  Symptoms  After  Different  Causes  of  Obstruction. — 
The  stages  of  (i)  insufificiency,  (2)  compensation,  and  (3)  atony  and 
dilation  with  the  attendant  stagnation  and  retention,  are  present  in 
all  forms,  except,  perhaps,  a  rapidly  developing  pyloric  carcinoma. 
In  the  benign  stenoses  the  first  period  is  generally  overlooked;  but 
dietetic  errors  bring  on  attacks  of  gastric  pain  of  increasing  severity, 
which  are  generally  relieved  by  vomiting.  The  vomited  food  con- 
tains, in  most  cases,  more  liquid  than  has  been  swallowed,  which  is 
explained  by  the  investigations  of  von  Mering,  who  demonstrated 
that  when  the  stomach  contained  absorbable  substances  (alcohol, 
salts,  sugar,  dextrin,  peptone)  and  their  transition  into  the  intestine 
is  prevented,  absorption  takes  place  more  or  less  in  the  stomach  itself, 
but  simultaneously  with  it  an  excretion  of  water  occurs  into  the 
stomach.  This  liquid  can  not  find  an  outlet  through  the  pylorus,  and 
is  expelled  during  the  attacks  of  vomiting.  The  vomit  under  such 
conditions  contains  an  abundance  of  mucus,  and  often  an  excess  of 
free  and  combined  HCl.  After  the  emesis  the  pain  subsides.  It  may 
happen  that  the  very  next  meal  may  pass  the  pylorus,  because  per- 
fect compensation  has  been  established.  There  is  invariably  a  per- 
sistent constipation.  At  the  onset  the  intermissions  between  the  at- 
tacks extend  for  months,  in  which  there  is  perfect  freedom  from  pain 
and  vomiting;  but  as  the  stage  of  atony  and  dilation  is  approached, 
the  stenosis  meanwhile  having  become  more  absolute,  the  attacks 
occur  more  frequently,  until  they  finally  take  place  regularly  after 
every  large  meal. 

When  the  period  of  stagnation  has  become  established,  pain  is 
usually  present  whenever  food  is  taken  into  the  stomach.  The  vomit 
gives  the  chemical  evidences,  and  sometimes  also  the  histological 
evidences,  of  gastritis.     In  the  retention  of  dilation  the  vomiting  is 


664  MOTOR  INSUFFICIENCY. 

not  so  frequent,  but  more  copious.  The  amount  of  free  and  com- 
bined HCl  gradually  becomes  less  and  less,  even  when  the  stenosis  is 
benign;  this  is  due  to  the  progressing  gastritis.  Now,  the  conditions 
favorable  to  the  development  of  lactic  acid  are  present;  these  are: 
(i)  Impaired  gastric  motility ;  (2)  absence  of  HCl ;  (3)  reduction  of 
albumen  digestion;  (4)  impaired  absorption;  and  (5)  presence  of 
lactic  acid  bacteria.  Acetic  and  butyric  acids  are  present  if  the 
original  substances  from  which  they  can  develop  were  contained  in 
the  food  (alcohol-butter).  The  gastric  contents  after  being  drawn 
separate  into  three  layers ;  and  if  the  stenosis  is  benign,  usually  con- 
tain the  products  of  pepsin  digestion.  The  quantity  of  urine  is  small, 
its  amount  being  in  proportion  to  the  degree  of  the  stenosis  and  reten- 
tion. The  appetite  is  lost,  severe  cachexia  develops,  and  the  case 
may  end  fatally  if  not  properly  treated.  The  foregoing  is  the  usual 
course  with  a  benign  stenosis,  such  as  may  occur  with  hypertrophy  of 
the  pylorus  or  benign  tumor. 

The  symptomatology  after  a  stenosis  due  to  gastric  ulcer  may  pre- 
sent peculiarities.  If  an  ulcer  is  located  in  the  pylorus,  it  may  begin 
with  its  usual  classical  signs  and  symptoms.  A  stenosis  may  develop 
from  the  inflammatory  swelling  and  induration  surrounding  the  ulcer ; 
or,  later  on,  as  a  result  of  cicatricial  contraction  when  the  ulcer  heals. 
Chronic  peptic  ulcer  still  in  its  progressive  stage  does  not  give  rise  to 
hemorrhage  nearly  so  frequently  as  the  acute  ulcer  located  in  other 
parts  of  the  stomach.  When  the  obstruction  is  developed,  there  is 
usually  vomiting,  occurring  from  one-half  to  three  hours  after  meals, 
but  occasionally  containing  food  taken  twelve  hours  previously. 

There  may  be  stagnation,  retention,  and  fermentation,  as  in  sten- 
osis caused  by  other  benign  obstructions.  We  have  observed  cases 
in  which  the  symptoms  of  vomiting,  pain,  and  retention  entirely 
disappeared  after  the  ulcer  was  brought  to  healing  by  proper  treat- 
ment. The  patients  remained  apparently  cured  for  a  period  varying 
from  sixmonths  to  two  years,  when  the  same  symptoms  and  evidences 
of  retention  returned,  which  in  a  number  of  our  cases  were  proved  to 
be  due  to  the  contracting  cicatrix  at  the  operation.  Thus,  the  clinical 
history  of  obstruction  due  to  peptic  ulcer  may  extend  over  as  many 
years  as  that  of  hypertrophic  stenosis. 

The  Appetite. — The  appetite  is  absent  in  carcinoma;  it  is  present 
or  exaggerated  in  ulcer  and  benign  hypertrophy;  as  a  rule,  it  will 
vary  with  the  state  of  gastric  cleanliness.  In  all  conditions  when 
there  is  much  gastric  fermentation,  the  appetite  is  diminished. 


SYMPTOMS    OF    PYLORIC    OBSTRUCTION.  665 

Thirst  is  normal  whenever  compensation  is  perfect ;  but  may  cause 
much  suffering  during  retention. 

Fullness,  Distention,  Pressure,  and  Pain. — The  overloaded 
stomach  gives  rise  to  a  sense  of  uneasiness.  The  increased  contrac- 
tions during  compensation  frequently  cause  distress.  The  contrac- 
tions of  a  hypertrophic  or  ulcerated  pylorus  cause  severe  pain,  which 
becomes  most  intense  when  a  struggle  occurs  between  the  antagonis- 
tic contractions  of  the  stomach  and  pylorus. 

Nausea  and  Vomiting. — These  symptoms  as  they  occur  in  gastri- 
tis, ulcer,  carcinoma,  hyperacidity,  hypertrophic  stenosis,  congenital 
pyloric  stenosis,  and  benign  tumors,  have  been  described  in  the 
chapters  devoted  to  these  subjects.  There  is  nothing  invariably 
characteristic  in  the  nature  and  chemical  composition  of  the  vomit 
in  these  various  conditions  by  which  a  diagnosis  could  be  arrived  at. 
The  chemical  differences,  as  far  as  they  are  of  diagnostic  value,  have 
been  described  in  the  chapters  referred  to. 

Emaciation,  Loss  of  Weight  and  Strength. — These  are  due  to 
the  albuminous  decomposition  brought  about  by  the  possible  carci- 
noma, but  more  frequently  by  the  fact  that  most  of  the  food  is  vom- 
ited and  can  not  enter  the  intestine.  It  is  possible  that  autointoxi- 
cation may  be  instrumental  in  the  bodily  denutrition.  It  must  not 
be  overlooked  that  the  modern  ideas  of  intestinal  autointoxication 
are  nothing  but  hypotheses,  and  lack  sufficient  experimental  founda- 
tion. That  there  is  some  truth  in  it  we  do  not  wish  to  deny,  but  much 
hard  and  well-directed  work  is  necessary  before  we  can  admit  of  the 
intestinal  autointoxication  theory  as  an  explanation  of  malnutrition. 

Tumor. — This  subject  has  been  thoroughly  ventilated  in  the 
chapter  on  Malignant  Neoplasm,  and  the  differentiation  of  gastric 
tumors  from  those  of  other  abdominal  organs  explicitly  stated.  It 
must  be  emphasized  again  that  when  the  pylorus  is  in  its  normal  posi- 
tion,— under  the  left  lobe  of  the  liver. — it  can  not  be  palpated,  even 
when  there  is  a  tumor  present.  In  a  case  recently  operated  upon,  by 
the  author's  suggestion,  by  Professor  L.  M.  Tiffany,  a  pyloric  tumor 
exceeding  the  size  of  a  man's  fist  was  firmly  attached  by  adhesions  to 
the  under  surface  of  the  liver.  This  large  cancerous  mass  could  not 
be  felt  because  it  was  firmly  held  under  the  liver  and  out  of  the  way 
of  any  possible  palpation. 

The  Cause  of  the  Stenosis  in  the  Duodenum. — When  gastric 
retention  and  dilation  are  caused  by  an  obstruction  in  the  duodenum, 
the  exact  definition  of  the  diagnosis  is  difficult.     Among  the  principal 


666  MOTOR  INSUFFICIENCY. 

causes  that  act  in  this  manner  are:  (i)  Twisting  and  torsion  of  the 
horizontal  part  of  the  duodenum,  brought  about  b}^  partial  rotation 
of  the  filled  stomach  when  the  abdominal  walls  are  very  much  relaxed 
(Kussmaul).  (2)  Indurated  ulcers  of  the  duodenum.  (3)  Carci- 
noma of  the  duodenum.  (4)  Carcinoma  of  adjacent  organs,  liver, 
gall-bladder,  pancreas,  colon,  omentum.  (5)  Gall-stones  projecting 
into  the  lumen  of  the  intestine,  and  acting  directl37^  as  an  obstruction, 
or  by  causing  an  adhesive  and  stenosing  inflammation.  In  a  case  de- 
scribed by  Mikulicz  in  which  the  stone  was  removed  by  gastrotomy, 
this  inflammatory  induration  had  occurred  immediately  below  the 
pylorus.  Among  the  causes  that  act  externally  to  the  duodenum  we 
should  mention  also,  in  addition  to  the  tumors  of  the  neighboring  or- 
gans referred  to,  enlarged  lymph-glands  in  the  mesentery.  (6)  Cica- 
tricial adhesions  after  round  ulcer,  or  purulent  gastritis,  or  former 
inflammations  of  the  peritoneum,  such  as  pericolitis,  or  appendicitis. 
(7)  Traction  and  distortion  of  the  duodenum  and  pyloric  region, 
induced  by  large  herniae,  especially  scrotal  (Rokitansky ) . 

It  is  very  doubtful  whether  right-sided  floating  kidney  can  com- 
press the  duodenum  sufficiently  to  produce  gastrectasis,  and  Leube, 
Ewald,  Oser,  Nothnagel,  and  Kuttner  have  advanced  convincing 
arguments  against  such  an  assumption.  This  error  was  probably 
due  to  the  confounding  of  dilation  or  gastrectasis  with  atony  and 
particularly  with  gastroptosis.  These  are  affections  that  occur 
simultaneously  with  floating  kidney,  and  are  probably  due  to  com- 
mon causes,  such  as  relaxation  of  the  abdominal  muscles,  stretching 
of  the  peritoneal  folds  known  as  ligaments.  I  agree  with  Riegel  that 
gastroptosis  is  not  rarely  combined  with  gastrectasis,  but  the  cause 
of  this  by  dislocated  kidney  is  not  proved ;  it  is  conceded,  however, 
that  a  dislocated  right  kidney  which  has  become  fixed  in  its  abnormal 
position,  or  a  kidney  that  has  increased  enormously  in  size  may  com- 
press the  duodenum  and  cause  a  dilation. 

A  definite  decision  concerning  the  various  causes  that  may  lead  to 
obstruction  of  the  pylorus  is  very  frequently  not  possible,  although 
every  attainable  diagnostic  moment  is  considered  carefully.  With 
the  status  of  our  present  knowledge  of  diseases  of  the  stomach  it  is 
impossible  to  recognize  the  beginning  of  pyloric  stenosis  with  preci- 
sion, and  the  practitioner  will  have  to  be  content  if  he  is  enabled  to 
decide  whether  the  dilation  and  retention  are  due  to  a  malignant  or  to 
a  benign  process.     In  the  writer's  experience  all  further  deductions 


RELATIVE   VALUE    OF    DIAGNOSTIC   FACTORS.  667 

made  from  the  clinical  phenomena  concerning  the  particular  nature 
and  origin  of  the  many  possible  varieties  of  benign  stenosis  are  largely 
conjectural.  The  differential  points  between  benign  and  malignant 
pyloric  stenoses  have  been  given  in  the  chapters  on  Carcinoma, 
Ulcer,  and  Hypertrophic  Stenosis;  but  for  the  sake  of  convenience, 
we  will  briefly  recapitulate  them  here. 

1.  Age. — Refer  to  the  tables  already  stated.  Malignant  tumors 
occur  at  a  more  advanced  age,  but  it  must  not  be  overlooked  that  the 
age  of  carcinomatous  patients  is  receding,  and  that  malignant  tumors 
may  occur  at  a  very  youthful  age;  therefore  this  moment  is  of  not 
much  utility  in  th-e  diagnosis. 

2.  Duration. — Benign  stenoses  last  for  many  years;  malignant 
processes  are  short,  generally  from  three  to  six  months,  only  excep- 
tionally exceeding  one  year. 

3.  Course  and  Progress. — In  benign  stenosis  these  are  very  vari- 
able. Periods  of  tolerable  well-being  or  even  of  good  health  alternate 
with  periods  of  severe  sickness ;  but  in  malignant  stenosis  the  aggra- 
vation of  the  symptoms  is  progressive  and  continuous,  notwithstand- 
ing rational  treatment. 

4.  Tumor. — The  most  important  deciding  element  of  the  diagno- 
sis of  pyloric  stenosis  will  be  the  demonstration  of  a  tumor,  but  in  the 
differentiation  between  benign  stenosis  and  carcinoma  the  existence 
of  tumor  is  of  little  value.  A  tumor,  if  present,  may  as  well  be  a 
benign  hypertrophy  as  cancer ;  and  if  it  is  absent,  it  does  not  exclude 
the  diagnosis  of  either  of  these  conditions. 

5.  Metastases. — If  these  can  be  palpated  in  other  abdominal 
organs, — for  instance,  in  the  liver  or  in  the  mesenteric  glands, — we 
have  a  strong  evidence  in  favor  of  malignant  process.  The  same 
may  be  said  of  swelling  of  the  cervical  lymph-glands  occurring  in  the 
left  supraclavicular  region.  This  complication  is,  in  our  experience, 
a  rare  occurrence. 

6.  Edema. — If  other  causes  that  may  bring  on  edema  of  the  ankles 
may  be  excluded,  the  presence  of  this  symptom  is  suggestive  of  a 
malignant  process,  but  absence  of  this  symptom  does  not  argue 
against  carcinoma.     It  is  a  late  symptom. 

7.  Hematemesis. — In  my  experience  blood  is  contained  in  the 
vomit  in  one-half  of  all  cases  of  gastric  cancer.  Large  quantities  of 
blood  are  rarely  vomited,  but  the  characteristic  coffee-ground  vomit, 
in  consequence  of  stagnation  and  decomposition  of  the  blood,  is  diag- 
nostically  important.     The  more  copious  the  effusions  of  blood  into 


668  MOTOR   INSUIfFlCIENCY. 

the  stomach,  the  quicker  do  they  cause  vomiting ;  for  that  reason  the 
abundant  hemorrhages  in  ulcer  are  often  vomited  uncoagulated  and 
very  httle  altered,  whereas  the  smaller  amounts  of  blood  in  carcinoma 
and  gastritis  remain  in  the  stomach  a  longer  time,  and  then  show  the 
characteristic  coffee-ground  appearance.  But  large  hemorrhages 
may  occur  in  cancer,  and  small  hemorrhages  may  occur  in  ulcer ;  and 
I  have  seen  cases  of  coffee-ground  vomiting  in  ulcer  repeatedly. 

8.  Chemistry  of  the  Gastric  Contents. — This  has  been  dwelt 
upon  in  the  chapters  on  Ulcer  and  Carcinoma.  Hyperchlorhydria  or 
hyperacidity  is  suggestive  of  a  cicatrix  or  cicatricial  tumor  formed 
from  an  ulcer.  It  also  occurs  in  the  ulcus  carcinomatosum,  the  car- 
cinomatous degeneration  of  the  peptic  ulcer.  Absence  of  free  HCl 
may  be  present  in  benign  as  well  as  malignant  stenosis.  Pepsin  and 
chymosin  are  present  in  the  benign  cases,  but  show  a  very  variable 
condition  proportionate  to  the  degree  of  destruction  of  the  mucosa 
in  malignant  conditions. 

9.  Lactic  acid  is  very  rare  in  benign  stenosis,  and  was  present  in 
eighty-two  per  cent,  of  all  cases  of  gastric  cancer  coming  to  the 
author's  clinic.     It  is  a  valuable  though  not  an  early  diagnostic  sign. 

10.  Hydrogen  Sulphid. — This  is  said  to  occur  frequently  in  be- 
nign, and  rarely  in  malignant,  stenosis.  In  the  author's  opinion  this 
sign  is  not  reliable. 

11.  Bacteriological  Evidences. — These  organisms  were  present 
in  fifty-three  out  of  fifty-five  cases  of  gastric  carcinoma,  and  are  of 
great  diagnostic  significance.  In  our  experience  they  have  not  been 
found  in  benign  stenosis,  though  I^indner  and  Kuttner  assert  that 
they  do  occur  in  such.  Sarcinse  occur  more  frequently  and  in  greater 
abundance  in  the  benign  stenosis. 

12.  The  presence  of  large  numbers  of  cells  in  a  state  of  atyp- 
ical mitosis  is,  in  the  writer's  opinion,  diagnostically  important. 
We  have  not  been  able  to  find  them  in  the  contents  of  eighteen  cases 
of  gastric  ulcer  and  a  much  larger  number  of  cases  of  chronic  gastritis, 
which  were  especially  examined  with  regard  to  this  factor.  The  study 
of  karyokinesis  in  cells  obtained  from  the  human  stomach  is  as  yet 
very  incomplete.  It  should  be  carried  out  in  a  large  number  of  gastric 
diseases  other  than  cancer.  Cells  in  a  state  of  atypical  mitosis  are 
early  signs  of  cellular  proliferation,  and  very  suggestive  of  malignant 
disease.  So  far,  very  few  cases  of  gastric  cancer  have  been  diagnosed 
by  this  method. 

13.  Fragments  of  Neoplasm. — While  these  clinch  the  diagnosis 


CONTINUED   SUPERSECRETION    AND    PYLORIC    OBSTRUCTION.      669 

of  carcinoma,  they  are  not  early  signs.  If  they  are  found  in  the  wash- 
water  without  any  special  effort  having  been  made  to  detach  them, 
the}^  come  from  tumors  that  are  in  a  state  of  disintegration,  and,  in 
my  experience,  often  were  found  to  have  already  induced  glandu- 
lar metastases. 

The  differential  diagnosis  between  benign  and  malignant  stenoses 
is  not  always  clear,  even  after  a  pyloric  tumor  can  be  palpated.  But 
when  no  tumor  can  be  palpated,  judgment  is,  indeed,  difficult,  and  is 
possible  only  after  frequent  and  prolonged  observations;  in  rare 
instances,  in  the  author's  experience,  the  diagnosis  could  not  posi- 
tively be  made  even  after  exploratory  laparotomy. 

The  differential  diagnosis  between  motor  insufficiency  due  to  ob- 
struction and  that  due  to  myasthenia  can  be  decided  in  favor  of 
the  former  whenever  a  tumor  can  be  palpated.  All  symptoms  of 
stagnation,  retention,  etc.,  have  no  differentiating  value;  neither  has 
the  chemistry  of  the  stomach  in  the  two  conditions.  These  and 
other  distinguishing  points  are  given  in  the  chapter  on  Motor  Insuf- 
ficiency. The  author  has  devised  a  method  by  which  a  tube  can 
be  passed  from  the  mouth  through  the  stomach  and  pylorus  into 
the  duodenum  (Hemmeter,  "Intubation  des  Duodenum,"  Boas, 
"Archiv  f.  Verdauungskrankh.,"  Bd.  ii,  Seite  85;  see  first  part  of 
this  volume).  This  method  is,  in  a  fair  proportion  of  the  cases, 
available  for  the  determination  for  the  permeability  of  the  pylorus. 
Similar  methods  have  been  described  by  Dr.  Fenton  B.  Turck  and 
F.  Kuhn.  Efforts  of  this  kind  to  sound  the  pylorus  give  promise 
of  diagnostic  aid  and  of  enlarging  the  means  of  treatment. 

Hyperacidity,  whenever  it  prolongs  gastric  digestion  and  causes 
distention,  does  so  by  causing  indigestion  of  the  carbohydrates,  or 
reflex  spasm  of  the  pylorus.  In  simple  hyperacidity  these  s^^mp- 
toms  can  be  relieved  by  internal  use  of  the  alkalies,  or  washing  the 
stomach  with  alkaline  solutions.  In  retention  due  to  obstruction 
the  alkaline  treatment  will  give  no  benefit.  As  a  rule,  in  our  ex- 
perience, the  motility  of  the  stomach  is  well  preserved  in  hyper- 
acidity. 

Continued  Supersecretion  and  Pyloric  Obstruction. — Gastro- 
succorrhea  chronica  and  dilation  of  the  stomach  occur  together  very 
frequently.  This  dilation  may  be  of  the  so-called  atonic  or  myas- 
thenic variety,  or  it  may  be  due  to  pyloric  obstruction ;  but  there  are 
dilations  without  chronic  continued  supersecretion,  and,  on  the  other 
hand,  this  secretory  anomaly  may,  according  to  Riegel  and  Reich- 


670  MOTOR  INSUFFICIENCY. 

mann,  occur  without  dilation.  The  origin  of  the  atonic  dilation  from 
a  continued  supersecretion  of  gastric  juice  is  explainable  by  the  fol- 
lowing facts:  The  permanent  presence  of  gastric  juice,  the  acidity 
of  which  may  increase  with  every  addition  of  food,  constitutes  an 
inhibition  to  carbohydrate  digestion.  The  starchy  foods  are  retained 
abnormally  long.  Then,  again,  if  a  continued  secretion  of  gastric 
juice  is  assumed,  the  stomach,  of  course,  is  never  entirely  empty, 
and  therefore  never  obtains  absolute  rest ;  and,  finally,  the  hyperacid 
contents  may  cause  a  pyloric  spasm,  preventing  the  exit  of  the  gastric 
chyme.  In  this  manner  gastrosuccorrhea  may  cause  obstruction  and 
retention.  Reversely,  pyloric  stenosis  may  keep  up  a  kind  of  con- 
tinued gastric  flow  by  holding  back  the  food  within  the  stomach.  It 
is  almost  impossible  to  decide  in  such  cases  whether  the  pyloric  steno- 
sis w^as  primary,  or  whether  it  was  superadded  to  an  alread}^  existing 
continued  supersecretion.  The  author  has  been  able  to  observe  a 
number  of  cases  from  their  very  incipiency,  and  concludes  that  both 
varieties  occur  clinically.  Even  among  those  who  devote  special  at- 
tention to  the  abnormalities  of  secretion  there  is  confusion  with  re- 
gard to  the  terms  hyperacidity  and  hyperchlorhydria  on  the  one  hand, 
and  chronic  continued  supersecretion  and  gastrosuccorrhea  on  the 
other.  We  may  have  retention  and  dilation  together  with  hyper- 
acidity; we  may  even  have  a  pyloric  stenosis  together  with  hyper- 
acidity ;  and  yet  there  will  be  no  sign  of  chronic  continued  secretion. 
Hyperacidity  means  an  increased  secretion  of  gastric  juice,  or  rather 
of  HCl,  during  digestion.  The  stimulus  to  this  increased  secretion 
is  the  normal  presence  of  food  in  the  stomach.  Hypersecretion  or 
continued  secretion  of  the  gastric  juice  is  an  abnormal  condition  in 
which  the  gastric  mucosa  secretes  continuously,  even  when  the  di- 
gestive stimulation  is  absent  and  the  stomach  contains  no  food. 
This  condition  may  be  intermittent  and  periodical,  or  it  may  be 
continuous. 

It  is  a  generally  accepted  fact  that  hyperacidity  predisposes  to 
gastric  ulcer,  but  continued  hypersecretion  renders  a  patient  much 
more  liable  to  the  development  of  ulcer  than  hyperacidity,  since  in 
the  continued  secretion  the  stomach  is  never  free  from  gastric  juice 
which  is  as  highly  acid  as  that  which  occurs  in  hyperacidity.  The 
development  of  dilation  from  continuous  hypersecretion  may  be  ex- 
plained by  the  presence  of  an  ulcer  in  the  pylorus,  which  may  have 
resulted  in  the  formation  of  a  stenosing  cicatrix.  Thus,  a  primary 
continued  secretion  may  give  rise  to  an  ulcer,  cicatricial  stenosis,  and 
a  consequent  secondary  dilation. 


DEGREE   OF    THE   OBSTRUCTION.  67 1 

Hyperacidity  represents  a  lesser  degree  of  irritation,  and  continued 
secretion  a  higher,  more  intensely  irritated  state  of  the  secreting 
gland-cells.  Undoubted  cases  have  occurred  in  which  hyperacidity 
was  intensified  and  developed  into  chronic  continued  hypersecretion. 
In  the  cases  in  which  the  dilation  and  retention  was  the  primary  con- 
dition and  the  hypersecretion  was  recognized  later  on,  it  is  not  abso- 
lutely certain  that  the  dilation  caused  the  hypersecretion ;  undoubted 
and  long-observed  cases  of  this  character,  with  careful  and  repeated 
chemical  and  physical  analyses,  have,  in  our  experience,  not  been 
published.  It  is  more  rational  to  assume  that  in  such  cases  the  dila- 
tion was  consequent  upon  an  ulcer  in  the  pylorus,  which  ulcer  had 
ar.'sen  on  the  basis  of  a  prolonged  hyperacidity.  After  the  dilation 
had  developed,  the  hyperacidity  was  intensified  into  a  chronic  con- 
tinued hypersecretion.  A  pronounced  stagnation  of  the  ingesta  con- 
sequent upon  a  dilation  may  very  much  resemble  a  continued  hyper- 
secretion. To  distinguish  between  these  two  conditions,  it  is  neces- 
sary to  examine  and  analyze  the  gastric  contents  in  the  morning 
before  any  food  has  been  taken.  In  continued  secretion  the  jejune 
stomach  should  always  contain  active  gastric  juice  in  quantities 
from  150  to  300  c.c.  This  gastric  juice  should  be  free  from  food 
remnants.  This  can  not  occur  in  simple  dilation — it  should  not  even 
occur  in  dilation  with  hyperacidity,  for  in  both  of  these  cases  we  will 
find  food  remnants,  particularly  undigested  carbohydrates.  The 
diagnosis  between  the  two  conditions  can  be  definitely  settled  by 
washing  out  the  stomach  thoroughly — until  the  lavage  water  comes 
out  absolutely  clear  and  shows  no  signs  of  acid.  This  must  be  done 
in  the  evening.  The  patient  must  not  eat  anything  in  the  mean 
while.  The  next  morning,  before  food  is  taken,  the  gastric  contents 
are  drawn  by  the  expression  method,  and  if  100  c.c.  or  more  of  gastric 
juice  without  any  traces  of  food  remnants  can  be  gained,  it  is  a  case 
of  continued  hypersecretion.  The  differentiation  between  dilation 
with  continued  hypersecretion  or  supersecretion  and  dilation  with 
simple  hyperacidity  hinges  upon  the  presence  or  absence  of  food  in 
the  stomach  when  it  is  prepared  as  just  described.  If  the  presence 
of  food  is  necessary  to  bring  out  the  secretion  of  gastric  juice  in  the 
stomach  in  the  morning,  it  is  a  dilation  with  hyperacidity ;  but  if  the 
stimulus  of  food  is  not  necessary,  it  is  a  dilation  with  continued  hyper- 
secretion. 

The  degree  of  the  obstruction  can  be  determined  by  the  amount 
of  our  double  test-meal,  or  of  the  test-meals  of  Herschell,  Riegel,  or 


672  MOTOR   INSUFFICIENCY. 

lycube,  that  remains  in  the  stomach  after  a  certain  time.  During 
compensation  the  stomach  succeeds  in  emptying  itself  in  perhaps  one 
hour  longer  than  the  normal  time.  During  stagnation  the  stomach 
requires  from  six  to  eight  hours  to  empty  itself  of  a  Riegel  dinner ;  but 
when  the  stagnation  is  advanced,  the  stomach  is  not  empty  except 
perhaps  before  breakfast.  In  retention  the  stomach  is  never  empty. 
The  degree  of  the  retention  can  be  measured  by  the  methods  given  in 
the  chapter  on  Motor  Insufficiency.  In  benign  stenosis  the  degree  of 
the  obstruction  may  be  gaged  by  the  author's  method  of  duodenal 
intubation. 

Prognosis. — The  prognosis  will  vary  with  the  cause.  It  is  grave 
in  malignant  obstruction;  and  even  in  benign  obstruction,  such  as 
peritonitic  adhesions,  ulcer  of  the  duodenum,  impacted  gall-stone, 
corrosive  gastritis,  etc.,  the  prognosis  is  grave.  If  the  stenosis  is  due 
simply  to  kinking  of  the  pylorus  or  duodenum  by  a  primary  atonic 
dilation,  the  prognosis  is  also  bad,  because  not  CA^en  surgical  aid  can 
be  depended  upon  to  relieve  this  condition  permanently. 

Treatment. — The  maxim  of  all  treatment  in  these  cases  should  be : 
' '  In  pyloric  obstruction  beware  of  wasting  valuable  time  with  purely 
medical  treatment."  The  medical  treatment  is  given  in  the  chapter 
on  Motor  Insufficiency.  It  is  very  much  to  be  regretted  that  the 
literature  of  the  subject  shows  no  well-observed  cases  in  which  un- 
doubted benign  stenosis  was  cured  by  purely  medical  means.  The 
plan  that  promises  the  best  results  is  to  decide  rapidly  upon  an  opera- 
tion, exclude  all  medicines  and  food  from  the  stomach,  maintain  the 
patient's  strength  by  rectal  alimentation,  and  administer  -g^Q-  of  a  grain 
of  strychnin  hypodermically  four  times  a  day.  During  the  period  of 
complete  compensation,  particularly  if  the  obstruction  is  benign,  the 
patients  will  rarely  consult  the  physician.  During  this  stage,  when 
the  periodical  attacks  of  vomiting  and  stagnation  begin,  the  diet 
should  be  that  of  motor  insufficiency  of  the  first  degree.  It  is  very 
difficult  to  convince  the  patient  of  the  necessity  of  operation  during 
this  stage,  and  even  during  the  stage  of  stagnation.  The  physician 
is  unfortunately,  therefore,  frequently  compelled  to  persist  in  purely 
medical  treatment,  notwithstanding  his  convictions  to  the  contrarj^ 

Lavage.— I  prefer  to  carry  out  lavage  during  stagnation  in  the 
evening,  according  to  Riegel's  plan.  The  last  meal  is  given  between 
four  and  five  o'clock  in  the  afternoon,  consisting  of  some  food  that 
will  readily  pass  the  pylorus,  even  though  it  may  be  partially  con- 
stricted.     Milk,  koumiss  or  matzoon,  the  whites  of  four  eggs,  egg 


TREATMENT   OF   BENIGN   STENOSIS.  673 

beaten  up  in  hot  beef  bouillon  with  four  grams  of  somatose  added, 
custard,  meat  pulp,  cream,  Zwieback  or  cake,  cerealin,  strained  oat- 
meal, strained  breakfast  wheat,  w^ell-boiled  rice,  soft-boiled  eggs, 
corn-meal  mush,  are  suggested  as  possible  articles  of  diet.  Great 
solubility  and  fluidity  of  the  food,  and  minute  subdivision  in  its  prep- 
aration are  desiderata  in  the  process  of  cooking.  Whenever  possi- 
ble, the  food  should  be  strained  or  passed  through  a  colander.  Soup 
made  of  sweetbread  in  beef  bouillon  has  a  high  caloric  value.  After 
such  a  meal  the  patient  must  lie  down  and  submit  to  gastric  massage. 
With  this  aid,  and  in  the  recumbent  position,  the  liquid  diet  is,  as  a 
rule,  out  of  the  stomach  in  five  hours ;  if  it  is  not,  there  is  no  need  of 
further  experimentation  with  dietetic  and  medicinal  treatment. 
After  the  meal  can  be  presumed  to  be  out  of  the  stomach,  the  organ  is 
thoroughly  washed  out  with  medicated  solutions  that  are  varied 
according  to  the  condition  of  the  gastric  chemistry.  If  no  HCl  is 
present,  it  is  well  to  use  first  sodium  chlorid,  one  teaspoonful  to  the 
quart  of  warm  water,  and  toward  the  end  of  the  operation  a  solution 
of  dilute  HCl,  say  a  3  to  4  :  1000  solution.  If  the  gastric  contents 
show  persistent  hyperacidity,  I  prefer  to  wash  out  the  stomach  with 
sodium  bicarbonate,  one  teaspoonful  to  the  quart,  followed  b}'  a  solu- 
tion of  nitrate  of  silver,  i  :  1000,  or  a  one-half  of  one  per  cent,  solu- 
tion of  tannin.  If  gastric  ulcer  is  suspected,  a  suspension  of  sub- 
nitrate  or  subgallate  of  bismuth  may  be  used  with  advantage,  one 
dram  to  the  quart  of  warm  water,  and  permitted  to  run  in  during  con- 
stant agitation  of  the  suspension  of  the  bismuth. 

In  addition  to  fine  subdivision  of  the  food,  the  next  most  important 
dietetic  principle  is  to  assure  one's  self  that  the  stomach  is  always 
empty  before  a  meal  is  permitted.  To  ascertain  this,  it  is  necessary 
to  learn  the  time  in  which  the  patient's  stomach  will  evacuate  itself, 
by  passing  a  stomach-tube  from  four  to  five  hours  after  a  meal  like  the 
Riegel  dinner,  or  by  employing  our  double  test-meal. 

The  stool  should  be  watched  and  suflicient  food  introduced  to  cover 
the  caloric  requirements  of  the  patient.  It  is  not  an  easy  matter  to 
gage  the  proper  amount  of  food  to  be  introduced  into  these  weak 
stomachs.  The  danger  of  overburdening  is  very  great.  It  is,  there- 
fore, advisable  to  give  two,  perhaps  three,  nutritive  enemata  a  day, 
which  will  permit  of  considerable  reduction  in  the  amount  of  food 
necessary  to  be  given  by  the  mouth. 

Dilation  of  Benign  Pyloric  Stenosis  by  Sounding. — This  method  has 
been  employed  by  the  author  in  obstruction  due  to  hypertrophic 


674  MOTOR   INSUFB'ICIENCY. 

stenosis  of  the  pylorus,  when  operation  was  refused.  The  cases  were 
markedly  relieved  for  a  time,  but  permanent  cure  of  the  obstruction 
by  this  method  seems  doubtful.  Nevertheless,  the  technics  of  this 
procedure  should  be  perfected  to  be  available  in  the  efforts  to  dilate 
cicatricial  and  hypertrophic  stenosis  whenever  operation  is  impossible 
or  refused.  (Concerning  the  indications  and  methods  of  operation, 
see  the  chapter  devoted  to  Surgery  of  the  Stomach,  or  the  Cartwright 
lectures  on  "Surgery  of  the  Stomach,"  by  W.  W.  Keen,  lyly.D., 
"Philadelphia  Medical  Journal,"  volume  i,  pages  829,  927,  1053,  ^^'^ 
1 104.) 

LITERATURE 

ON   DILATION   OF  THE  STOMACH. 

1.  AbriiTis,  A.,  "  Gistrectatic  Dyspnea,"  "Pacific  Rec.  M.  and  S.,"  San 
Francisco,  iSgS-'gp,  xiii,  39-42. 

2.  Alex,  "Stenose  du  pylore  d'origine  biliaire,"  These  de  Lyon,  97. 

3.  Anderson,  "  British  Med.  Jour.,"  May  10,  1890. 

4.  Von  Anrep,  "Da  Bois'  Archiv,"  1881. 

5.  Armstrong,   W.,   "Gastric   Dilation,"  "  Brit.   Med.    Jour.,"   Lond.,    1898, 

1,949- 

6.  Ashby,   H.,  "A  Case    of  Congenital  Stenosis  of  the  Pylorus,"    "Arch. 

Pediat.,"  New  York,  1897,  xiv,  498-505. 

7.  Aufrecht,  "  Centralbl.  f.  klin.  Med.,"  1893,  Nr.  23. 

8.  Bardet,  "  Bull.  Gen.  de  Therap.,"  1884,  329. 

9.  Bartels,  "  Berl.  klin.  Wochenschr.,"  1877,  Nr.  30. 

10.  Von  Basch,  "Berl.  klin.  Wochenschr.,"  1889,  Nr.  19,  S.  433. 

11.  Bauermeister,  Inaug.- Dissert.,  Halle,  1890. 

12.  Baum,  "Wien.  med.  Presse,"  Nr.  17,  1873. 

13.  Beau,  "Gaz.  Med,  de  Paris,"  No.  5,  i860. 

14.  Beaumetz,  D.,  et  D.  Ettinger,  "Union  Medicale,"  29  Janvier,  1884. 

15.  Beaumont,  "  Experiments  on  the  Gastric  Juice,"  1838. 

16.  Benedict,  A.  L.,  "  Diagnosis  of  the  Gastric  Conditions  Producing  Ischo- 
chymia  (Atony,  Gastroptosis,  Atonic  Dilation,  Obstructive  Dilation),"  "  Med. 
Age,"  Detroit,  1898,  xvi,  386-392. 

17.  Beurmann,  "Gaz.  Hebd.,"  No.  14,  1889. 

18.  Bettmann,  H.  W.,  "Acute  Dilation  of  the  Stomach,"  "Cincin.  Lancet- 
Clinic,"  1897,  N.  S.,  XXXVIII,  569-575. 

19.  Bettmann,  H.  W.,  "Motor  Insufficiency  of  the  Stomach,"  "Cincin. 
Lancet-Clinic,"  1897,  xxxvin,  517-522,  Discussion,  525;  also,  "  Tr.  Acad. 
Med.,"  Cincin.,  i897-'98. 

20.  Bircher,  H.,  "  Correspondenzbl.  f.  Schweizer  Aerzte,''  1891,  Nr.  23. 

21.  Boas,  "  Diagnostik  u.  Therapie  der  Magenkrankheiten,"  2.  Theil,  S.  ill, 
Leipzig,  1893. 

22.  Boas,  "  Deutsche  med.  Wochenschr.,"  1893,  Nr.  39,  und  "  Munchener 
med.  Wochenschr.,"  1893,  Nr.  43. 

23.  Boas,  "Hypertrophic  Stenosis  of  the  Pylorus  and  its  Treatment,"  "Arch, 
f.  Verdauungskrankh.,"  Apr.  i,  1898. 


LITERATURE.  675 

24.  Bokai,  A.,  "  Wirkung  des  Ouassin  betr.,"  "  Pester  med.-chirurg.  Presse," 
1893,  Nr.  45. 

25.  Bouveret,  "  Stenose  du  pylore  adherent  a  la  vesicule  calculeuse," 
"R6vue  de  Med.,"  Jan.,  1896. 

26.  Bouveret,  "  Sur  le  diagnose  de  Testomac  biloculaire  par  I'insufflation," 
"Lyon  Medicale,"  2,  11,  1896. 

27.  Bouveret  et  Devic,  "  Revue  de  Medec,"  1892,  H.  i  und  11. 

28.  Boyd,  M.  A.,  "  A  Clinical  Lecture  on  the  Significance  of  Dilation  or 
Gastreclasia  in  Functional  and  Organic  Diseases  of  the  Stomach,"  "  Brit.  Med. 
Jour.,"  London,  1897,  il,  265,  266. 

29.  Broadbent,  W.  H.,  "  Dilation  of  the  Stomach,"  "  Practitioner,"  Lon- 
don, 1898,  LX,  11-28. 

30.  Brown,  R.  Hill,  "  Case  of  Dilation  of  the  Stomach  Complicated  by 
Fatal  Tetany,"  "  Lancet,"  21,  iii. 

31.  Bruhl,  "  Gaz.  des  Hopitaux,"  1891. 

32.  Bugge,  "  Tidschrift  f.  pract.  Med.,"  Nr.  10,  1881. 

33.  Buist,  S.  Somers,  "  Amer.  Jour,  of  Med.  Sciences,"  Oct.,  1870. 

34.  Carr,  W.,  "A  Case  of  Dilation  of  the  Stomach  Associated  with  Per- 
ipheral Neuritis,"  "  Lancet,"  London,  1897,  11,  721. 

35.  Carrel,  "  L'estomac  biloculaire  (presentation  de  la  piece),"  Soc.  des 
Science  Med.  de  Lyon,  Mai,  1896. 

36.  Cautley,  E.,  "  Congenital  Hypertrophic  Stenosis  of  the  Pylorus," 
"  Lancet,"  London,  1898,  11,  1264. 

37.  Cecchini,  S.,  "  Rassegna  di  Scienza  mediche,"  1886. 

38.  Chauffard,  "Stenose  pylorique  ;  gastroenteroanastomose,  etat  du  malade 
trois  mois  apres  I'operation,  Presentations  de  malade,"  Soc.  Med.  des  Hop., 
22  Oct.,  1896. 

39.  Chauffard,  A.,  "Stenose  pylorique  et  vaste  dilatation  de  l'estomac; 
application  au  diagnostic  de  I'eclairage  electrique  intra  stomacal,"  "  Bull,  et 
Mem.  Soc.  Med.  d.  Hop.  de  Par.,"  1897,  3  S.,  xiv,  979-982. 

40.  Chiari,  "Wien.  med.  Blatt,"  Nr.  3,  1881. 

41.  Chomel.  "Des  Dyspepsies,"  Paris,  1857. 

42.  Comby,  J.,  "  Dilatation  de  l'estomac  chez  les  nourrissons,"  "  Bull,  et 
Mem.  Soc.  Med.  d.  Hop.  de  Par.,"  1897,  3  S.,  850-857. 

43.  Comby,  "  Dilatation  de  I'estornac  chez  le  enfants,"  Soc.  Med.  des  Hop., 
18  Juin,  1897. 

44.  Comby,  "Arch.  Gen.  de  Med.,"  Aout,  1884. 

45.  Cordier,  A.  H.,  "  Gastro-jejunostomy  in  Gastrectasis,"  "Med.  Record," 
25,  IX,  1897. 

46.  Coyon,  A.,  "Stenoses  du   pylore,"  "Gaz.  d.  hop.,"  Paris,  1898,  Lxxr, 

917.  945- 

47.  Debove,  Soc.  Med.  des  Hopit.,  12  Dec,  1886. 

48.  Dehio,  "  Verhandlungen  d.  Cong.  f.  innere  Med.,"  1888. 

49.  Deiters,  Inaug.-Dissert.,  Greifswalde,  1889. 

50.  Donkin,  "The  Lancet,"  Sept.  27,  1890. 

51.  Duchon-Doris,  These  de  Paris,  1887. 

52.  Dujardin-Beaumetz,  "  Berl.  klin.  Wochenschr.,"  1890,  Nr.  31. 

53.  Dunin,  "  Resultate  der  Gastroenterostomie  bei  narb.  Pylorusstenose," 
"  Centralbl.  f.  Chirurg.,"  1893,  Nr.  36. 

45 


676  MOTOR  INSUFFICIENCY. 

54.  Einhorn,    V.,    "  Ueber    elektr.    Magen-    und     Darmdurchleuchtung," 
"Therap.  Monatshefte,"  1892,  S.  128. 

55.  Einhorn,  "  Berl.  klin.  Wochenschr.,"  1891,  Nr.  23. 

56.  Einhorn,  M.,  "  A  Further  Contribution  to  our  Knowledge  of  Ischochy- 
mia,"  "Med.  Rec,"  New  York,  1877,  li,  865-873. 

57.  Erdmann,  "  Virchow's  Archiv,"  Bd.  XLlir,  S.  295. 

58.  Ewald,  "Berl.  klin.  Wochenschr.,"  1890,  Nr.  12. 

59.  Ewald,  "Therap.  Monatshefte,"  August,  1887. 

60.  Fagge,  Hilton,  "Guy's  Hosp.  Rep.,"  xviii ;  "  Virchow's  Jahresb.,"  1873, 
B.  H.,  S.  155. 

61.  Fleiner,  "  Ueber  die  Behandl.  einiger  Reizerschein.  u.  Blut.  des  Magens," 
"  Verhandlungen  d.  Cong.  f.  innere  Med.,"  1894,  S.  309. 

62.  Francois,  L.,  "  Sur  une  volumineuse  dilation  stomacale,"  "  Marseille 
Med.,"  1897,  XXXIV,  372-374. 

63.  Francon,  "  Lyon  Med.,"  7  Aout,  1887. 

64.  Von  Frankl-Hochwart,  "Die  Tetanie,"  Berlin,  1891. 

65.  Friedenwald,  J.,  "  Two  Interesting  Cases  of  Dilation  of  the  Stomach," 
"Maryland  Med.  Jour.,"  Baltimore,  i897-'98,  xxxviii,  153-155. 

66.  Galliard,  Assoc.  Fran^aise,  Congres  de  Rouen,  1883. 

6"].  Galvagin,  E.,  "  Gastrectasia  da  stenosi  pilorica,"  "  Gazz.  d.  osp.," 
Milano,  1898,  XIX,  777-77<). 

68.  Garcia,  E.  L.,  "  Dilatacion  del  estomago  sin  estinosis  pilorica,"  "  Cron. 
med.  Lima,"  1897,  xiv,  393;  411,  1898;  xv,  6,  25,  61. 

69.  Garcia,  Duarte  R.,  "  De  la  gastro-ectasia,"  "  Gac.  med.  de  Granada," 
1898,  XVI. 

70.  Gerhardt,  "Berl.  klin.  Wochenschr.,"  S.  74,  Januar,  1888. 

71.  Gillet,  A.,  "  Dyspepsie  et  dilatation  gastro-intestinale  chez  I'enfant," 
"  Rev.  gen.  de  Clin,  et  de  Therap.,"  Paris,  1897,  XI,  325-327. 

72.  Grundzach,  "  Wien.  med.  Presse,"  Nr.  28,  1891. 

73.  Hamill,  S.  McC,  "  Dilated  Stomach  from  Pyloric  Obstruction  ;  Con- 
tracted Kidneys,"  "  Tr,  Path.  Soc.  of  Phila.,"  1898,  xviii,  75-78. 

74.  Hayem,  G.,  "  Note  sur  les  variations  de  la  capacite  stomacale  dans  les 
stenoses  pyloriques,"  "  Bull,  et  Mem.  Soc.  Med.  d.  Hop.  de  Paris,"  1897,  3  S., 
XIV,  1322-1325. 

75.  Hayem,  "  Stenose  pylorique,"  "  Presse  Med.,"  20  Novembre,  1897. 

76.  Hayem,  "Stenose  sous  pylorique  incomplete,"  "Med.  Moderne,"  9 
fevrier,  1898. 

77.  Heynsius,  "  Weekblad  van  het  Nederlandsch.  Tydschrift  voor  Ge- 
neesk.,"  Nr.  37,  1874. 

78.  Hirschberg,  These  de  Paris,  1889. 

79.  Hochenegg,  J.,  "  A  Case  of  Hour-glass  Stomach  Cured  by  Gastroanas- 
tomosis,"  "  Wien.  klin.  Wochenschr.,"  July  16,  1898. 

80.  Hofmann,  "  Anzeiger  d.  Ges.  d.  Aerzte  in  Wien,"  Nr.  12,  1881. 

81.  Hoppe-Seyler,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  L,  C.  S.  82. 

82.  Huber,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  XLVll. 

83.  Hufschmidt,  "  Wien.  klin.  Wochenschr.,"  1893,  Nr.  3. 

84.  Hunter,  "New  York  Med.  Record,"  p.  273,  1889. 

85.  Jacobson  und  Ewald,  "Ueber  Tetanie,"  "Verhandlungen  d.  Congr.  f. 
innere  Medizin,"  1895,  S.  298. 

86.  Jago,  "Med.  Times  and  Gaz.,"  Oct.  12,  1872. 

87.  Jaworski,  "Wien.  med.  Wochenschr.,"  No.  16,  1888. 


LITERATURE.  677 

88.  Jobin,  A.,  "Un  cas  de  dilatation  aigue  de  I'estomac,"  "Rev.  Med.," 
Quebec,  1897,  i,  177. 

89.  Von  Joliann,  Peter  Frank,  "  De  cur.  horn.  morb.  epit.,"  lib.  v,  pars.  6, 
p.  666. 

90.  Jiirgensen,  Th.  v.,  "  Tod  unter  schweren  Hirnerscheinungen  bei  hoch- 
gradiger  Erweiterung  des  Magens,"  "  Archiv  f.  klin,  Med.,"  Bd.  LX,  p.  327. 

91.  Kansche,  "  Unters.  liber  die  funkt.  Resultate  von  Operat.  am  Magen." 

92.  Kelynack,  T.  N.,  "  Gastrectasis  Secondary  to  Malignant  Stricture  of  the 
Pylorus,"  "Med.  Press  and  Circ,"  London,  1898,  N.  S.,  Lxv,  5. 

93.  Kern,  Inaug.-Dissert.,  Berlin,  1891. 

94.  Klemperer,  "  Ein  Fall  geheilter  Magenerweiterung,"  "  Deutsche  med. 
Wochenschr.,"  1889,  Nr.  9. 

95.  Krasnobayeff,  T.  P.,  "  Three  Cases  of  Stricture  of  the  Pyloric  Portion  of 
the  Stomach  in  Childhood,"  "  Dietsk.  med.  Mosk.,"  1898,  in,  195-204. 

96.  Kuckein,  R.,  "A  Case  of  Latent  Tetany,  with  Dilation  of  the  Stomach, 
in  Consequence  of  Carcinomatous  Stenosis  of  the  Pylorus,"  "  Berl.  klin. 
Wochenschr.,"  Nov.  7,  1898. 

97.  Kuhn,"  Zeitschr,  f,  klin.  Med.,"  1892,  Heft  5  u.  6. 

98.  Kuhn,  "  Deutsche  med.  Wochenschr.,"  1892,  Nr.  49  u.  52. 

99.  Kussmaul,  "Zur  peristalt.  Unruhe  des  Magens,"  "  Volkm.  klin.  Vor- 
trage,"  Nr.  181. 

100.  Kuttner  und  Jacobson,  "Berl.  klin.  Wochenschr.,"  1892,  Nr.  39  u.  40. 
loi.  Landau,  "  Die  Wanderniere  der  Frauen,"  Berlin,  1881. 

102.  Landerer,  Inaug.-Dissert.,  Freiburg,  1879. 

103.  Laprevotte,  These  de  Paris,  1884. 

104.  Lefevre,  "Archiv  Gen.  de  M6d.,"  tome  xiv  et  xv,  1842. 

105.  Leichtenstern,  "  Ziemssen's  Handbuch,"  2.  Aufl.,  Bd.  vii,  2,  S.  411-418. 

106.  Leo,  "  Diagn.  der  Krankh,  d.  Verdauungsorgane,"  p.  41,  Berlin,  1892. 

107.  Lepoil,  "These  de  Paris,"  1881. 

108.  Leube,  "Archiv  f.  klin.  Med.,"  Bd.  xviii,  S.  207. 

109.  Lindemann,  E.,  "  Demonstration  von  Rontgenbildern  des  normalen 
und  erweiterten  Magens,"  "  Deutsche  med.  Wochenschr.,"  1897,  xxiii,  266. 

no.  Litten,  "  Verhandlungen  des  VL  Congr.  f.  innere  Med.,"  1887. 

111.  Lyman,  H.  M.,  "Dilation  of  the  Stomach,"  "Jour.  Amer.  Med. 
Assoc,"  1897,  xxviii. 

112.  Maier,  R.,  "Congenital  Pyloric  Stenosis,"  "  Virchow's  Archiv," 
Bd.  cii. 

113.  Malibran,  These  de  Paris,  1885. 

114.  Marten,  "Lancet,"  April  2,  1890,  p.  230. 

115.  Mattheides,  Inaug.-Dissert.,  Erlangen,  1890. 

116.  Maynard,  E.  F.,  "Chronic  Dilation  of  the  Stomach  Associated  with 
Chronic  Gastric  Catarrh,"  "  Brit.  Med.  Jour.,"  London,  1898,  11,  1126. 

117.  Mazotti,  Luigi,  "  Rivista  Clinica  di  Bologna,"  Aoiit  et  Sept.,  1824. 

118.  McKendrick,  John  S.,  "Case  of  Tetany  with  Dilation  of  the  Stomach; 
Death,"  "  Lancet,''  Sept.  24,  1898. 

119.  McNaught,  "Dilation  and  Eructation  of  Inflammable  Gas,"  "Brit. 
Med.  Jour.,"  1890. 

120.  Von  Mering,  "  Ueber  die  Funktion  des  Magens,"  "  Verhandl.  d.  Congr. 
f.  innere  Med.,"  1893. 

121.  Meltzer,  S.  J.,  "On  Congenital  Hypertrophic  Stenosis  of  the  Pylorus  in 
Infants,"  "  Med.  Rec,"  New  York,  Aug.  20,  1898. 


678  MOTOR   INSUFFICIENCY. 

122.  Meyer,  "  Virchow's  Archiv,"  Bd.  cxv,  S.  326. 

123.  Michalis,  Walter,  "Ueber  die  Erweiterung  des  Antrum  pylori  und  ihre 
Beziehung  zu  der  motorischen  Insufficienz  des  Magens,"  "  Zeitschr.  f.  klin. 
Med.,"  Bd.  xxxiv,  S.  241. 

124.  Moncorvo,  Rio  de  Janeiro,  broch.,  1883. 

125.  Montaya,  These  de  Paris,  1881. 

126.  Montprofit,  "  Obstruction  du  pylore  par  un  calculi  biliare,"  "  Soc.  anat. 
Bullet.,"  de  Mai-Juin,  1897. 

127.  Monyour,  "  Dilatation  de  I'estomac  par  stenose  du  pylore  ;  gastro- 
enterostomie  par  le  precede  G.  Dubourg,  guerison,"  Soc.  d'Anat.  et  de  Phys.  de 
Bordeaux,  4  Octob.,  1897. 

128.  Moritz,  "Gastric  Motility  with  Regard  to  Liquids  and  Semi-liquids," 
"  Verhandl.  d.  Naturforsch.-Versamml.,"  Wien,  1894. 

129.  Miiller,  F.,  "  Charite  Annalen,"  p.  283,  1888. 

130.  Mueller- Warnek,  "  Berl.  klin.  Wochenschr.,"  Nr.  30,  429,  1877. 

131.  Naunyn,  "Gastric  Fermentation  and  Motor  Insufficiency,"  "  Deutsch. 
Arch.  f.  klin.  Med.,"  Bd.  xxxi,  82. 

132.  Nauwerk,  D.,  "Archiv  f.  klin.  Med.,"  Heft  5  u.  6,  vol.  xxi,  p.  573,  1878. 

133.  Neumann,  "Deutsche  Klinik,"  Nr.  2  u.  3,  1861. 

134.  Newmann,  "Lancet,"  Dec.  5,  1868. 

135.  Oppolzer,  "  Magenerweiterung,"  "  Wien.  med.  Wochenschr.,"  1893. 

136.  Oser,  Artikel,  "Magenerweiterung"  in  Eulenburg's  "  Realencyclo- 
padie." 

137.  Pacanowski,  "  Zur  physikal.  Diagnostik  d.  mechan.  Insuff.  d.  Magens." 

138.  Parker,  R.,  "A  Series  of  Operations  for  Dilated  Stomach,"  "  Liverpool 
Med.-Chir.  Jour.,"  1898,  xviii,  274-282. 

139.  Patek,  A.  J.,  "Atony  of  the  Stomach,"  "Med.  News,"  New  York,  1898, 
LXXiii,  584-587. 

140.  Penzoldt,  "  Die  Magenerweiterung,"  Erlangen,  1875.  (History  of  the 
subject.) 

141.  Penzoldt  (in  Penzoldt  und  Stintzing's  "  Handbuch  d.  speciellen  Ther- 
apie  innerer  Krankheiten,"  Bd.  iv). 

142.  Penzoldt-Faber,  "  Berl.  klin.  Wochenschr.,"  1882,  Nr.  21. 

143.  Pepper,  "  Phila.  Med.  Times,"  May  i,  1871. 

144.  Pepper,  W.,  and  Alfred  Stengel,  "  Diagnosis  of  Dilation  of  the  Stom- 
ach," "  Amer.  Jour.  Med.  Sciences,"  Jan.,  1898. 

145.  Perret,  "  L'estomac  biloculaire,"  These  de  Lyon,  1896. 

146.  Pertick,  "Archiv  f.  path.  Anat.  u.  Phys.,"  CXIV,  1888,  Heft  3,  S.  98. 

147.  Petriquin,  "  Bulletin  de  Therap.,"  X,  p.  239. 

148.  Phaundler,  M.,  "  So-called  Congenital  Stenosis  of  the  Pylorus  and  its 
Treatment,"  "Wien.  klin.  Wochenschr.,"  Nov.  10,  1898. 

149.  Plempius,  et  suivants,  cites  par  D.  Beaumetz,  "  Traitement  des  mal  de 
I'Estomac,"  Paris,  1893. 

150.  Poensgen,  "  Motor-Verricht.  d.  menschl,  Magens,"  Strassburg,  1882. 

151.  Pope,  C,  "A  Clinical  Lecture  on  Gastric  Dilation,"  "Charlotte, 
N.  C,  Med.  Jour.,"  1897,  xi,  171-176. 

152.  Popofif,  "Berl.  klin.  Wochenschr.,"  1870,  Nr.  38  u.  40. 

153.  Preble,  R.  B.,  "  Gastrectasis,  with  a  Tetanoid  Condition  and  the  So- 
called  Pulmonary  Hypertrophic  Osteoarthritis  of  Marie,"  "Jour.  Amer.  Med. 
Assoc,"  1898,  XXX,  217-219. 


LITERATURE.  679 

154.  Purjesz,  Sigmund,  "  Deutsches  Arch.  f.  klin.  Med.,"  Bd.  xxiir,  S.  554, 
1879. 

155.  Quincke,  "  Dilation  with  Rupture  into  Colon,"  "  Correspondenzbl.  f. 
Schweizer  Aerzte,"  1874. 

156.  Reed,  B.,  "  Dilation  of  the  Stomach,  with  Reports  of  Cases  Treated 
by  Diet,  Massage,  and  Intragastric  Electricity,"  "Jour.  Amer.  Med.  Assoc," 
1898,  XXXI,  220-223. 

157.  Reed,  W.  W.,  "Report  ot  a  Case,  with  Remarks  upon  the  Diagnosis 
of  Pyloric  Stenosis,"  "Colorado  Med.  Jour.,"  Denver,  1898,  iv,  139-144. 

158.  Reichmann  und  Heryng,  "  Ueber  Gastrodiaphanie,"  "  Berl.  klin. 
Wochenschr.,"  1892,  Nr.  51. 

159.  Remond  (de  Metz),  "  Gaz.  des  Hopit.,"  14  Nov.,  1891. 

160.  Revilliod,  "  Revue  de  Med.  de  la  S.  Romande,"  No.  i,  1885. 

161.  Riegel,  "  Zur  Diagnose  u.  Behandlung  der  Magenerweiterung," 
"  Deutsche  med.  Wochenschr.,"  1886,  Nr.  37. 

162.  Riegel,  "Ueber  Diagnostik  u.  Therapie  der  Magenkrankheiten," 
"  Volkmann's  klin.  Vortrage,"  Nr.  289. 

163.  Robson,  A.  W.  Mayo,  "Tetany  and  Tetanoid  Spasms  Associated  with 
Gastric  Dilatation  Treated  Surgically,"  "  Lancet,"  Nov.  26,  1898. 

164.  Rosenbach,  "  Berlin,  klin.  Wochenschr.,"  Nr.  51,  S.  742,  1876. 

165.  Rosenheim,  "Ueber  d.  Verhaltn.  d.  Magenfunkt.  nach  Resekt.  des 
carcinomat.  Pylorus,"  "  Deutsche  med.  Wochenschr.,"  1892,  Nr.  40. 

166.  Rosenheim,  F.,  "  Ueber  motorische  Insufficienz  des  Magens,"  "  Berlin, 
klin.  Wochenschr.,"  1897,  XXIV,  228,  252  ;  Discussion,  256. 

167.  Rosenthal,  "  Magenneurosen  und  Magenkatarrh,"  Wien,  1886,  S.  181. 

168.  Rosenthal,  A.,  "  Preliminary  Note  on  Disorders  of  Mobility  of  the 
Stomach,  Myasthenia,  Atony,  and  Ectasia,"  "  Chicago  Med.  Recorder,"  1898, 
XV,  176. 

169.  Rossler,  A.,  "  Ueber  die  Ausschaltung  der  Ernahrung  durch  den  Magen 
bei  Dilatatio  ventriculi,"  "  Wien.  klin.  Wochenschr.,"  1893,  Nr.  40. 

170.  Rousseau,  G.,  "  De  la  dilatation  d'estomac  chez  les  nourrissons," 
These  de  Paris,  25,  xi,  1896. 

171.  Rupstein,  "  Archiv  f.  Anat.  u.  Physiol.,"  1874. 

172.  Rydygier,  "Zur  Magendarmchirurgie,"  "Wien.  klin.  Wochenschr.," 
1894,  Nr.  10. 

173.  Saundby,  "  Deutsche  med.  Wochenschr.,"  Nr.  42,  1896. 

174.  Schliep,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xiii,  S.  445. 

175.  Schmidt,  "Berlin,  klin.  Wochenschr.,"  1886,  No.  33. 

176.  Schmidt-Monnard,  "  Hour-glass  Stomach,"  "  Miinch.  med.  Wochen- 
schr.," 1893. 

177.  Schreiber,  "Archiv  f.  Verdauungskrankh.,"  Bd.  11,  S.  423. 

178.  Schwyzer,  T.,  "A  Case  of  Congenital  Hypertrophy  and  Stenosis  of  the 
Pylorus,"  "  N.  Y.  Med.  Jour.,"  21,  xi,  1897. 

179.  See,  G.,  et  A.  Mathieu,  "  Rev.  de  Med.,"  10  Mai  et  18  Sept.,  1884. 

180.  Senator,  "  Ueber  einige  neuere  Arzneimittel,"  "  Berl.  klin.  Wochen- 
schr.," 1885,  Nr.  I. 

181.  Senator,  "On  Autointoxications,  etc.,"  "  Zeitschr.  f.  klin.  Med.,"  Bd. 
VII,  1884. 

182.  Sievers,  R.,  "On  tetanie  vid  dilatation  of  magsaken,"  "  Finska  lak. 
sallsk.  handl.,"  Helsingfors,  1898,  XL,  18-39. 

183.  Sittmann,  "  Miinch.  med.  Wochenschr.,"  1893,  Nr.  29. 


68o  HEMORRHAGE  FROM   THE   STOMACH. 

184.  Stockton,  C.  G.,  "  Gastrectasis  from  Pyloric  Spasm,"  "  Internat.  Clin.," 
Phila.,  1898,  8  S.,  I,  126-128. 

185.  Stoker,  "  Hour-glass  Contract.  Stomach,"  "  Med.  Press  and  Circ," 
March  3,  1869. 

186.  Talma,  "  Indicat.  z.  Magenoperationen,"  "  Berl.  klin.  Wochenschr.," 
1895. 

187.  Tappeiner,  "  Zeitschr.  f.  Biol.,"  Bd.  v,  471. 

188.  Thiebaut,  These  de  Nancy,  1884. 

189.  Tilger,  "  Traction  Diverticulum  of  Pyloric  Region,  Caused  by  Disloca- 
tion of  the  Gall-bladder,"  "  Virchow's  Archiv,"  Bd.  cxxxiii,  Heft  2;  the 
same  author,  "  Congenital  Stenosis  of  the  Pylorus"  (/.  c). 

190.  Traube-Kundrat,  "  Handbuch  d.  Kinderkrankh.,"  Bd.   iv. 

191.  Traube,  "  Gesammelte  Abhandlungen,"  1871. 

192.  Thorowgood,  "  Lancet,"  17  Fev.,  1872. 

193.  Wagner,  "Berl.  klin.  Wochenschr.,"  Nr.  16,  S.  229,  und  Nr.  25,  S.  361, 
18.  April  und  20.  Juni,  1881. 

194.  Wegele,  "  Die  diatet.  u.  medicament.  Behand.  d.  Magendarmerkrank.," 
Jena,  1896. 

195.  Weiss,  H.,  "  Der  Sanduhrmagen,"  "  Mittheil.  a.  d.  Grenzgeb.  d.  Med. 
u.  Chin,"  Jena,  1897-98,  i,  393-398. 

196.  Winternitz,  "  Deutsche  Medicinalzeitung,"  1891,  Nr.  38. 

197.  Winternitz  und  Baum,  "  Wien.  med.  Presse,"  1873,  Nr.  17. 

198.  Zabludowski,  "Zur  Massagetherapie,"  "Berl.  klin.  Wochenschr.,"  1886, 
Nr.  26  ff.  u.  36. 

199.  V.  Ziemssen,  "  Ueber  physik.  Behandl.  chron.  Magendarmerkrankung," 
Leipzig,  1888. 


CHAPTER  VIII. 
HEMORRHAGE  FROM  THE  STOMACH  (GASTRORRHAGIA). 

This  s^^mptom  as  it  occurs  in  consequence  of  gastric  ulcer  and  car- 
cinoma has  ahready  been  described  in  the  chapters  devoted  to  these 
subjects.  Hematemesis,  or  vomiting  of  blood,  is  not  a  synonymous 
term  with  gastric  hemorrhage,  for  the  vomited  blood  may  have  had 
its  origin  in  the  respiratory  passages,  and  have  been  swallowed.  It 
may  have  come  from  the  esophagus  or  from  the  duodenum.  Then, 
again,  there  may  be  undoubted  gastric  hemorrhage  without  hema- 
temesis. 

The  cause  of  the  gastric  hemorrhage  may  be  found  in  injurious  in- 
fluences coming  from  without,  or  developing  within,  the  stomach. 

Etiology. — I.  Gastric  Ulcer. — This  is  the  most  frequent  cause  of 
hemorrhage.  Tuberculous,  S5^philitic,  or  typhoid  ulcers  of  the  stom- 
ach are  extremely  rare ;  and  even  in  those  cases  that  are  reported  they 


ETIOLOGY   OF    GASTRORRHAGIA.  68 1 

are  seldom  mentioned  as  causes  of  hemorrhage.  Professor  William 
Osier  described  a  case  of  profuse  gastric  hemorrhage  to  the  author 
which  was  caused  by  a  typhoid  ulcer  of  the  stomach  occurring  at  the 
Johns  Hopkins  Hospital.  Erosions  of  the  stomach,  as  such,  do  not, 
in  my  experience,  cause  hemorrhage,  but  when  they  are  digested  out 
by  hyperacidity  or  supersecretion,  they  may  break  into  the  walls  of  a 
blood-vessel ;  then,  however,  we  can  no  longer  speak  of  an  erosion :  it 
has  become  a  peptic  ulcer. 

2.  Malignant  Tumors  of  the  Stomach. — Carcinoma  and  sarcoma. 

3.  Benign  Tumors  of  the  Stomach. — These  are  rare  causes  of  hemor- 
rhage. 

4.  Mechanical,  Chemical,  and  Thermic  Causes. — (a)  Acting  from 
without,  such  as  direct  traumatism,  or  injury  to  the  abdomen;  pene- 
trating wounds  of  the  abdomen  affecting  the  stomach.  (6)  Acting 
from  within :  swallowed  foreign  bodies,  such  as  fish-bones,  pins,  etc. 
(c)  Corrosive  chemical  poison,  such  as  mineral  acids  and  caustic 
alkalies;  poisons  swallowed  by  mistake  or  with  suicidal  intent,  (d) 
Exceedingly  hot  substances,  (e)  The  HCl  itself  in  a  state  of  hyper- 
acidity or  supersecretion  may  erode  small  blood-vessels  in  places 
where  the  circulation  is  abnormal,  where  there  are  blood  extravasa- 
tions, emboli,  or  thrombi.      (/)  Injury  caused  by  the  stomach-tube. 

5.  Disease  of  the  Gastric  Blood-vessels. — (a)  Galliard  found  miliary 
aneurysms  of  the  arteries  of  the  stomach  as  a  cause  of  fatal  hemor- 
rhage. (6)  The  gastric  veins  may  be  affected  by  varices,  this  condi- 
tion being  generally  associated  with  chronic  passive  congestion  of  the 
stomach.  Recently,  L-ancaster  has  reported  a  case  of  fatal  gastric 
hemorrhage  in  a  woman  aged  thirty-three  years.  At  the  autopsy 
varicose  dilatation  of  several  branches  of  the  gastro-epiploic  vein  in 
the  greater  omentum  and  in  the  submucosa  of  the  stomach  were 
found.  The  largest  ones  of  these  varices  showed  a  rupture  as  large 
as  a  pin  ("Miinchen.  med.  Wochenschr.,"  1896,  Nr.  45).  (c)  Fatty 
atheromatous  and  amyloid  degeneration  of  the  gastric  blood-vessels. 
No  reliable  autopsy  reports  could,  however,  be  found  in  which  gastric 
hemorrhage  was  due  to  amyloid  degeneration  of  the  blood-vessels. 
Gastric  hemorrhage  in  phosphorus-poisoning  is  attributed  to  fatty 
degeneration  of  the  arteries. 

6.  Active  congestion  of  the  stomach  usually  is  a  result  of  intense 
acute  inflammation,  which  inevitably  brings  on  inflammatory"  altera- 
tions in  the  vessel  walls.  W.  H.  Welch  assigns  the  so-called  vica- 
rious hemorrhages  from  the  stomach  to  active  congestion.     As  a 


682  HEMORRHAGE   FROM   THE    STOMACH. 

result  of  a  large  experience  in  cases  of  gastric  hemorrhage,  the  author 
can  confirm  that  periodic  gastric  hemorrhages  occur  simultaneously 
with  the  menstrual  period.  In  amenorrhea  one  occasionally  observes 
periodic  gastric  hemorrhages.  Sometimes,  when  a  young  female  is 
afflicted  with  a  gastric  ulcer,  the  hemorrhages  may  coincide  with  the 
menstrual  terms.  Whether  such  hemorrhages  are  "vicarious"  or 
not  is  difficult  to  decide.  This  term  means  "substitutive,"  and  is 
applied  to  the  assumption  of  functions  of  one  organ  by  another.  In 
our  opinion  gastric  hemorrhage  can  hardly  substitute  the  physiologi- 
cal process  of  menstruation.  It  has  been  assumed  that  suppressed 
hemorrhoidal  hemorrhage  and  epistaxis  may  be  substituted  by  a 
gastric  hemorrhage — a  very  hypothetical  suggestion. 

7.  Passive  congestion  of  the  stomach,  resulting  from  some  obstruc- 
tion to  the  portal  circulation.  Such  obstruction  can  occur  (a)  in  the 
portal  vein  itself  or  in  its  branches  within  the  liver,  as  in  cirrhosis  of 
the  liver,  neoplasms,  echinococcus-cysts  pressing  on  the  portal  vein; 
also  in  pylethrombosis  and  cholecystitis.  Obstruction  to  the  flow 
of  bile,  and  consequent  dilatation  of  the  bile-ducts  in  the  liver,  and 
pigment  deposits  in  melanemia  may  cause  occlusion  of  the  capillaries 
in  a  similar  way.  (6)  The  obstruction,  may  occur  from  failure  of  com- 
pensation in  valvular  and  other  diseases  of  the  heart,  (c)  In  the  pul- 
monary blood-vessels  caused  by  emphysema,  chronic  pleurisy,  and 
fibroid  indurations  of  the  lungs.  During  violent  acts  of  vomiting 
gastric  hemorrhage  is  occasionally  observed,  and  may  be  explained 
by  the  venous  congestion  of  the  mucous  membrane  of  the  stomach. 
Such  hemorrhages  have  been  observed  by  the  author  during  vomiting 
of  pregnancy  and  sea-sickness.  The  veins  in  the  muscular  layer  of 
the  stomach  are  much  more  likely  to  be  compressed  during  the  violent 
contractions  of  the  gastric  muscularis  than  are  the  arteries.  Obstruc- 
tion to  the  pulmonary  or  cardiac  circulation  is  not  so  frequent  a  cause 
of  gastric  hemorrhage  as  obstruction  in  the  portal  vein  or  the  liver. 
Next  to  ulcer  and  cancer  of  the  stomach,  cirrhosis  of  the  liver  is  the 
most  frequent  cause  of  gastric  hemorrhage. 

8.  Acute  Infectious  Diseases. — The  manner  and  process  by  which 
gastric  hemorrhage  is  brought  about  in  these  diseases  are  not  well 
understood.  It  is  usually  explained  by  the  dissolution  of  the  blood- 
corpuscles  and  alterations  in  the  walls  of  the  blood-vessels.  In  a  few 
instances  only  was  the  hemorrhage  found  to  be  due  to  plugging  of 
the  vessels  with  bacteria.  The  gastrorrhagia  in  acute  5'ellow  atrophy 
of  the  liver  has  been  attributed  to  the  simultaneous  action  of  a  variety 


NEPHRITIS — MELENA.  683 

of  causes — for  instance,  dissolution  of  the  blood  by  bacteria  or  bile 
constituents,  together  with  obstruction  of  portal  circulation  due  to 
disease  and  occlusion  of  the  hepatic  capillaries.  The  infectious  dis- 
eases that  are  generally  assigned  as  causes  of  gastric  hemorrhage  are 
yellow  fever,  acute  yellow  atrophy  of  the  liver,  malaria,  relapsing 
fever,  cholera,  typhoid  fever,  typhus  fever,  erysipelas,  diphtheria, 
small-pox,  measles,  and  scarlet  fever. 

9.  Certain  Constitutional  Affections. — (a)  Scorbutus,  purpura, 
hematophilia,  and  other  affections  inducing  a  hemorrhagic  diathesis. 
(6)  Various  forms  of  anemias ;  progressive  pernicious  anemia,  chloro- 
sis, leukocythemia,  and  pseudoleukocythemia.  (c)  Malaria.  The 
author  has  lived  in  the  malarious  regions  of  Virginia  and  Maryland 
along  the  Chesapeake  Bay,  and  can  assert  from  extensive  experience 
that  this  disease  is  capable  of  causing  hemorrhage  from  the  stomach. 
Not  only  are  the  hemorrhages  cured  by  quinin,  but  the  malarial  or- 
ganism has  been  found  by  the  writer  in  the  vomited  blood.  Hans 
Herz,  in  his  new  contribution,  ' '  Die  Storungen  des  Verdauungsappa- 
rates  als  Ursache  und  Folge  anderer  Erkrankungen, "  admits  the  in- 
fluence of  malaria  in  bringing  about  these  gastric  affections.  We 
may  distinguish  (i)  the  periodical  malarial  gastric  hemorrhage  (cura- 
ble by  quinin) ;  (2)  the  pernicious  malarial  gastric  fever;  (3)  gastric 
hemorrhages  due  to  extreme  anemia  brought  about  by  malarial 
cachexia;  (4)  cholemia.  This  is  attributed  to  dissolution  of  the 
blood-corpuscles  by  biliary  constituents. 

10.  Nephritis. — In  very  rare  instances  hemorrhage  from  the  stom- 
ach has  been  reported  in  connection  with  contracted  kidneys.  Wm. 
H.  Welch  found  the  cause  of  a  fatal  gastric  hemorrhage  in  one  such 
case  to  be  due  to  the  bursting  of  a  miliary  aneurysm  of  a  small  artery 
in  the  submucous  coat,  and  he  considers  that  all  similar  hemorrhages 
occurring  in  such  cases  are  referable  to  disease  of  the  vessel  walls 
(Pepper's  "System  of  Medicine,"  vol.  ii,  p.  582). 

11.  Melena  Neonatorum. — An  extravasation  of  blood  into  the 
stomach  and  intestines  of  the  new-born  infant,  occurring  most  often 
in  the  first  few  hours  of  life.  Targe  quantities  of  blood  are  lost  by  the 
intestinal  evacuations  or  by  vomiting.  The  origin  of  this  disease  is 
very  obscure.  In  some  cases  it  seems  to  be  an  infection;  in  others, 
scorbutus  or  hemophilia  seems  to  lie  at  the  foundation.  In  rare 
cases  gastric  and  duodenal  ulcers  have  been  found.  Landau  ("Ueber 
Melane,"  Habilitationsschrift,  Breslau,  1875)  and  others  have  as- 
cribed it  to  embolism  of  the  umbilical  veins.     They  presume  that 


684  HEMORRHAGE   FROM   THE    STOMACH. 

thrombi  become  detached  from  this  vein  and  the  ductus  arteriosis, 
and  reach  the  gastric  or  intestinal  arteries.  W.  Soltau  Fen  wick 
("Disorders  of  Digestion  in  Infancy  and  Childhood")  reports  a  case 
in  which  postmortem  examination  failed  to  explain  the  origin  of  the 
bleeding,  but  when  the  vessels  of  the  stomach  were  subsequently  in- 
jected, a  large  vein  was  discovered  close  to  the  cardiac  orifice,  through 
an  aperture  in  which  the  injection  poured  out  in  great  quantities. 
Fenwick  correctly  suggests  that  in  man}'^  cases  the  cause  of  the  bleed- 
ing is  not  detected  because  postmortem  contraction  of  the  mucous 
membrane  may  have  obliterated  the  signs  of  rupture  of  some  varicose 
vein  in  the  stomach  or  bowel.  Among  twenty  cases  recorded  by  Ril- 
liet  and  Barthez  ("Trait,  des  Malad.  de  I'enfance,"  2d  edition,  vol.  11, 
pp.  295-310),  nine  exhibited  melena  within  thirty-six  hours,  and  sev- 
enteen before  the  sixth  day.  Silbermann  ("Gerhardt's  Handbuch," 
IV,  S.  415)  reported  thirty-seven  cases,  in  twenty-seven  of  which  the 
hemorrhage  occurred  within  the  first  two  days.  The  clinical  picture 
of  this  fatal  infantile  disease  is,  in  brief,  about  as  follows :  The  child  is 
very  anemic,  the  evacuations  consist  of  thick,  dark  blood,  and  are 
followed  by  collapse  or  great  restlessness.  The  stools  succed  one  an- 
other in  rapid  succession,  and  soon  consist  entirely  of  bright  blood. 
The  hemorrhage  from  the  bowels  continues  for  about  twenty-four 
hours ;  hematemesis  is  not  so  frequent.  If  the  loss  of  blood  is  exces- 
sive, the  infant  succumbs  to  heart  failure ;  but  even  in  the  less  severe 
cases,  in  which  it  gradually  improves,  it  will  remain  anemic  for  many 
weeks,  or  eventually  die  of  some  acute  gastrointestinal  disease.  The 
mortality  of  melena  is  variously  stated  at  from  sixty  to  seventy-five 
per  cent. 

E.  von  Preuschen  ("Centralbl.  f.  Gynakol.,"  xviii,  9,  1894)  bases 
his  explanation  on  the  fact  that  blood  extravasations  were  found  in 
the  brains  of  the  infants  simultaneously  with  melena.  Accordingly, 
he  regards  the  brain  lesion  as  the  cause  of  the  disease.  Sufiice  it  to 
say  that  frequently  no  blood  extravasation  has  been  found  in  the 
brain  in  these  cases,  and  that  it  may  also  rationally  be  interpreted  as 
the  contemporaneous  expression  of  the  same  severe  constitutional 
disturbances.  F.  Gartner  ("Archivf.  Gynakol.,"  XLV,  1893)  claims 
to  have  discovered  the  cause  of  an  infectious  disease  in  infants  analog- 
ous to  melena.  In  fact,  he  calls  this  organism  the  bacillus  of  melena. 
His  researches  have,  as  yet,  not  been  confirmed.  Grynfelti  ("Arch. 
de  Tocol.  et  Gynecol.,"  Bd.  xix,  Nr.  6)  compares  melena  to  the  dis- 
encumberinsf  discharge  of  blood  occurring:  throus^h  the  hemorrhoidal 


IDIOPATHIC    HEMORRHAGE.  685 

veins  in  chronic  diseases  of  the  liver.  It  is  not  impossible  that  the 
sudden  closure  of  the  umbilical  artery  may  cause  a  collateral  over- 
filling of  the  other  abdominal  organs.  L.  Fischer  ("Miinch.  med. 
Wochenschr.,"  XLiv,  1897)  suggests  that  such  an  excess  of  blood  may 
be  caused  by  a  late  ligation  of  the  umbilical  cord,  but  all  of  these 
explanations,  although  very  interesting,  are  conjectural. 

12.  Nervous  Conditions. — The  experiments  of  Schiff,  Brown- 
Sequard,  Ebstein,  and  Ewald  make  it  probable  that  injury  to  the  cere- 
bral peduncles — optic  thalami,  corpus  striatum,  the  crura,  and  the 
anterior  corpora  quadrigemina — may  cause  gastric  hemorrhages  and 
formation  of  peptic  ulcers.  This  is  a  justifiable  deduction  when  we 
are  dealing  with  physiological  experiments,  but  there  is  no  evidence 
that  gastric  hemorrhage  sufficient  to  be  of  clinical  importance  can  be 
caused  by  lesions  of  the  central  nervous  system.  A  number  of  the 
most  conservative  authors  hold  that  gastric  hemorrhages  occur  in 
hysterical  women.  Personally,  I  have  had  no  opportunity  to  observe 
an  unmistakable  case  of  hemorrhage  from  the  stomach  in  a  hysterical 
woman  that  could  not  be  explained  in  some  other  way.  I  do  not  wish 
to  deny  that  it  occurs,  but  the  chance  of  deception  by  crafty  patients 
is  great.  It  should  be  mentioned  in  this  connection,  that  in  patients 
suffering  from  undoubted  gastric  ulcers  hemorrhages  are  liable  to 
occur  after  psychical  and  emotional  excitement.  Hemorrhages 
from  the  stomach,  which  have  been  reported  to  occur  in  locomotor 
ataxia,  in  tubercular  meningitis,  in  epilepsy,  and  in  progressive  paral- 
ysis of  the  insane,  may  be  classified  under  this  heading,  but  are  largely 
attributable  to  other  causes. 

13.  The  Rupture  of  Abscesses  or  of  Aneurysms  from  Adjacent  Organs 
into  the  Stomach. 

14.  Idiopathic  Gastric  Hemorrhage. — Wm.  H.  Welch  (/.  c.)  assigns 
a  place  to  hemorrhage  attributed  to  this  cause,  quoting  from  Flint 
("Principles  and  Practice  of  Medicine,"  5th  edition,  p.  513);  "Hem- 
orrhage sometimes  occurs  from  the  stomach,  as  from  the  bronchial 
tubes,  the  Schneiderian  membrane,  and  in  other  situations,  without 
any  apparent  pathological  connections,  neither  following  nor  preced- 
ing any  appreciable  morbid  conditions.  It  is  then  to  be  considered 
as  idiopathic."  Apparently  healthy  persons,  it  is  claimed,  suddenly 
have  profuse  gastric  hemorrhages,  which  are  followed  only  by  symp- 
toms immediately  referable  to  the  bleeding.  They  develop  no  further 
symptoms,  and  often  have  no  other  hemorrhage. 

Personally,  we  consider  that  so-called  idiopathic  causes  should  have 


686  HEMORRHAGE    FROM   THE    STOMACH, 

no  place  in  the  etiology  of  gastric  hemorrhage.  The  sources  of  error 
are  too  great  to  be  eliminated  by  a  microscopic  examination  of  the 
stomach.  AA'e  have  already  referred  to  the  cases  of  Lancaster  and 
Soltau  Fenwick  of  fatal  hemorrhages  resulting  from  pin-point  open- 
ings in  gastric  vessels.  Orth  and  Chiari  have  reported  similar  cases. 
Capillary  hemorrhages  can  very  often  not  be  demonstrated  at  all. 
One  must  not  overlook  the  fact  that  hemorrhage  from  the  stomach  is 
not  the  only  cause  of  hematemesis.  The  source  of  the  blood,  which 
may  have  gained  access  to  the  stomach,  may  be  in  the  mouth,  nose, 
throat,  bronchial  tubes,  esophagus,  or  the  duodenum.  Ewald  ("Real- 
Bncyklopadie, "  3.  Aufi.,  xiv,  " Magenkrankheiten, "  p.  288)  reports  a 
case  of  fatal  gastric  hemorrhage  with  absolutely  no  lesion  in  the  stom- 
ach or  anywhere  in  the  digestive  tract.  A.  Frankel  (' '  Deutsche  med. 
Wochenschr.,"  1894)  reported  a  case  of  fatal  gastric  hemorrhage  in  an 
anemic  patient  due  to  slight  capillary  erosions. 

Pathology. — It  can  not  be  considered  the  object  of  this  work  to 
describe  the  manifold  lesions  that  are  found  after  death  from  gastric 
hemorrhage.  It  is  sometimes  very  difficult  to  find  the  source  of  fatal 
gastric  hemorrhage.  Often  it  has  proved  fruitless.  In  such  cases 
writers  have  overcome  the  difficulty  by  assigning  the  cause  of  the 
hemorrhage  to  diapedesis,  and  not  to  rupture  of  a  blood-vessel.  In 
most  cases  of  gastrorrhagia  the  outpouring  of  blood  is  ver}^  sudden  and 
profuse,  and  the  conception  of  diapedesis  does  not  justify  the  belief 
that  the  red  corpuscles  can  escape  through  the  unruptured  walls  of 
blood-vessels  with  that  combined  rapidity  and  abundance  that  is  nec- 
essary to  explain  the  typical  gastric  hemorrhage  (Welch,  /.  c).  In 
Welch's  case  of  bursting  of  a  miliar}'  aneurj'sm,  over  an  hour  of  con- 
tinuous searching  was  required  to  find  the  pin-hole  perforation  in  the 
bottom  of  which  lay  the  small  aneur\^sm.  The  erosion  in  Chiari 's  case 
("Prag.  med.  Wochenschr.,"  '82,  Xr.  50)  was  not  larger  than  a  hemp- 
seed.  The  more  painstaking  and  careful  the  search  after  the  source  of 
the  hemorrhage  is  made,  the  more  frequently  will  a  definite  ana- 
tomical lesion  be  found  as  the  cause.  Injection  of  the  gastric  ves- 
sels with  some  highly  colored  fluid  aids  in  finding  the  ruptured  vessel. 

Symptomatology. — There  are  cases  of  undoubted  gastric  hemor- 
rhage that  present  no  symptoms  whatever.  \*ery  small  amounts  of 
blood  do  not  lead  to  vomiting,  and  are  not  sufficient  to  produce  visi- 
ble alterations  in  the  stools.  As  a  rule,  patients  do  not  observe  the 
character  of  their  stools.  Very  frequentlv  the  stools  are  not  even 
observed  by  the  attending  physician.      It  follows  that  it  is  possible 


SYMPTOMATOLOGY    OF    GASTRORRHAGIA.  687 

for  large  gastric  hemorrhages  to  escape  detection  when  the  blood  es- 
capes exclusively  by  way  of  the  intestines.  In  cases  of  sudden  pallor 
and  weakness,  as  occur  in  patients  suffering  from  gastric  diseases,  and 
even  in  such  as  have  hitherto  presented  no  history  of  gastric  disease, 
the  stools  should  by  all  means  be  examined.  The  symptoms  that 
lead  up  to  gastric  hemorrhage  are  described  in  the  chapters  on  Ulcer 
and  Carcinoma.  The  symptoms  that  are  directly  brought  about  by 
the  loss  of  blood  are,  in  severe  cases,  fainting,  unconsciousness,  and 
convulsion;  but  when  the  hemorrhage  has  not  been  profuse,  the 
patient  feels  a  progressive  weakness  and  languor.  Sometimes  a  giddi- 
ness, vertigo,  tinnitus,  and  flashes  before  the  eyes  are  complained  of. 
In  copious  bleeding,  nausea  and  vomiting  are,  as  a  rule,  produced; 
but  whether  the  bleeding  was  copious  or  not,  the  symptoms  of  anemia 
sooner  or  later  become  evident.  The  appearance  of  the  vomited 
blood  will  vary  according  to  the  time  it  has  remained  in  the  stomach 
prior  to  emesis,  according  to  the  source  of  the  hemorrhage, — that  is, 
whether  it  be  arterial  or  venous, — and  the  condition  of  the  gastric 
juice,  and  whether  remnants  of  food  were  in  the  stomach  at  the  time 
the  rupture  of  the  vessel  occurred.  Food  that  has  remained  in  the 
stomach  for  a  longer  time  assumes  a  dark-brown  or  chocolate  color 
or  the  appearance  of  coffee-grounds  under  the  action  of  the  gastric 
juice.  The  quantity  may  vary  from  thirty  grams  to  one  liter  or  more. 
It  is  sometimes  difficult  to  estimate  the  total  quantity  of  blood  that 
has  been  lost,  because  a  certain  portion  of  the  blood  is  invariably  lost 
by  the  stools.  In  certain  cases  the  entire  quantity  of  blood  lost  by 
rupture  of  a  gastric  blood-vessel  passes  into  the  intestines;  larger 
admixtures  of  blood  to  the  stool  can  be  easily  recognized  when  the 
administration  of  iron  or  of  bismuth  can  be  excluded.  Smaller  quan- 
tities can  not  be  recognized  by  inspection.  In  this  case  some  of  the 
tests  described  in  chapter  xiii  will  have  to  be  gone  through. 

Although  a  hemorrhage  has  been  very  copious,  it  may  be  repeated 
several  times — at  short  interv^als. 

Rise  of  Temperature  After  Gastric  Hemorrhage. — After  a  copious 
loss  of  blood,  rise  of  temperature  can  be  experimentally  produced  in 
animals.  This  fever,  which  has  been  termed  anemic  fever,  is  not 
peculiar  to  gastric  hemorrhages,  but  occurs  in  a  similar  manner  from 
hemorrhages  from  other  organs.  It  was  first  emphasized  by  Teich- 
tenstern  that  a  mild  or  a  high  fever  is  a  frequent  and  even  regular 
phenomena  of  gastric  hemorrhage  caused  by  peptic  ulcer.  This  does 
not  signify  that  fever  indicates  that  the  hemorrhage  has  come  from 


688  HEMORRHAGE   FROM   THE)    STOMACH. 

an  ulcer;  it  is  frequently  observed  in  hemorrhages  from  carcinoma, 
and  even  from  the  hemorrhage  resulting  from  passive  congestion  in 
certain  forms  of  chronic  gastritis.  It  is  quite  well  known  that  fever 
usually  follows  venesection.  The  term  anemic  fever  merely  suggests 
that  it  occurs  with  various  hemorrhages  leading  to  anemia.  The 
intensity  of  the  febrile  reaction  is  largely  influenced  by  two  factors — 
viz.,  the  rapidity  and  the  quantity  of  the  hemorrhage.  Small  hemor- 
rhages are,  as  a  rule,  not  followed  by  elevation  of  temperature.  The 
pathological  physiology  of  this  fever  is  very  obscure.  In  advanced 
anemia  the  blood  stagnates  in  the  internal  organs,  while  the  periph- 
eral parts  become  deficient  in  blood  and  cooler,  and  the  rate  of  the 
blood-current  is  considerably  reduced ;  thus  the  loss  of  heat  from  the 
surface  is  diminished,  and  the  heat  of  the  internal  parts  is  increased. 
In  the  author's  opinion  this  is  the  most  probable  explanation.  Other 
theories  explain  the  fever  by  an  invasion  of  bacteria  through  the  rup- 
tured blood-vessel;  by  the  resorption  of  putrefying  blood-masses 
from  the  intestine;  and  by  the  assumption  that  advanced  anemia 
stimulates  the  heat  centers  in  the  medulla. 

This  fever  may  last  several  days,  and  is  accompanied  by  marked 
acceleration  of  the  pulse.  The  rate  of  the  beat  can  frequently  be 
determined  only  by  auscultation  over  the  heart,  the  radial  pulse 
being  frequently  imperceptible.  Notwithstanding  this,  the  impulse 
of  the  apex-beat  may  appear  intensified. 

The  Disturbances  of  Sight — Blindness  After  Gastric  Hemorrhages. — 
These  are  extraordinary  and  rare  complications  of  copious  loss  of 
blood  from  the  stomach,  and  are  known  to  occur  after  hemorrhages 
from  other  organs.  But  although  hemorrhages  from  other  organs  are 
frequent,  disturbances  of  sight,  as  a  consequence,  occur  only  excep- 
tionally. It  has  been  argued  that  in  uterine  hemorrhages  the  slow- 
ness of  the  effusion,  and  in  traumatic  hemorrhages  the  otherwise 
healthy  condition  of  the  patient,  prevents  a  development  of  eye 
phenomena.  It  is  well  known  that  copious  hemorrhages  from  the 
lungs  in  phthisical  patients  are  not  followed  by  optic  phenomena. 
Blindness  has,  however,  been  observed  after  very  violent  attacks  of 
vomiting  unaccompanied  by  any  evidence  of  hemorrhage,  which  sug- 
gests that  perhaps  the  act  of  emesis  may  be  instrumental  in  the  pro- 
duction of  these  eye  symptoms. 

These  disturbances  of  sight  may  occur  immediately  after  the  hem- 
orrhage, but,  as  a  rule,  they  do  not  appear  until  from  the  fifth  to  the 
eighth  day,  but  they  have  been  observed  as  late  as  the  twenty-fourth 


DIAGNOSIS    OF    GASTRORRHAGIA.  689 

da5^  Slight  attacks  of  amatirosis,  amblyopia,  or  even  transient  blind- 
ness, are  sometimes  overlooked  because  other  graver  symptoms  step 
to  the  foreground,  and  when  the  strength  of  the  patient  is  very  much 
spared,  owing  to  extreme  prostration,  there  is  little  opportunity  for 
using  and  testing  the  eyesight.  Fortunately,  the  disturbances  of  sight 
disappear  in  the  majority  of  cases,  but  in  others  permanent  blindness 
of  one  or  both  eyes  may  result.  The  usual  result  is  recovery  with  a 
slight  defect  of  sight,  such  as  irregularities  in  the  visual  field,  color- 
blindness, etc.  Forster  has  observed  extravasations  in  the  retina 
and  grayish  clouding  around  the  papilla  immediately  after  the  hemor- 
rhage. In  some  cases  these  changes  did  not  produce  any  symptoms 
whatever,  in  other  cases  they  led  to  atrophy  of  the  optic  nerve.  Ac- 
cording to  Knies,  ophthalmoscopical  examination  is  often  entirely 
negative;  at  other  times  he  found  merely  a  pale  papilla  and  very 
narrow  blood-vessels,  and  finally  complete  atrophy  of  the  optic  nerve 
such  as  occurs  in  retrobulbar  neuritis.  In  a  few  cases  he  claims  to 
have  observed  complete  choked  disc,  and  finally  in  a  number  of  cases 
an  entirely  normal  fundus  and  papilla. 

The  cause  of  the  eye  affection  is  not  known.  Gowers  attributes 
it  to  an  influence  in  the  nature  of  shock  on  the  nerve  elements  of  the 
retina.  Forster  supposed  that  malnutrition  of  the  nerve-fibers, 
swelling,  and  clouding  occurred  through  absorption  of  water  from 
the  vitreous  substance.  Ziegler  demonstrated  fatty  degeneration 
in  the  optic  nerve  and  retina,  particularly  in  the  neighborhood  of  the 
lamina  cribrosa;  results  which  he  attributes  to  ischemia.  Ulrich 
assumes  a  circulatory  disturbance  at  the  edges  of  the  papilla  where 
the  retinal  vessels  are  bent  in  a  sharp"  angle ;  this  compels  the  intra- 
ocular pressure  to  remain  unchanged,  while  the  general  blood  pres- 
sure rapidly  sinks.  Knies  locates  the  changes  in  the  optic  nerve 
itself,  not  in  the  retina. 

There  ^re  disturbances  of  sight  after  gastric  hemorrhages  which 
appear  to  be  of  cerebral  origin.  They  are  usually  not  permanent, 
but  clinically  they  are  distinguishable  from  those  previously  de- 
scribed. The  reaction  of  the  pupil  is  preserved ;  there  may  be  total 
blindness,  or  hemianopia. 

Diagnosis. — In  all  cases  of  hematemesis  it  will  be  necessary  first 
to  decide  whether  the  material  vomited  is  really  blood,  because  a 
color  more  or  less  resembling  that  of  altered  blood  may  be  produced 
in  the  vomit  by  iron,  bismuth,  claret,  fruits, — such  as  blackberries, 
mulberries,  cranberries, — and  bile.    One  or  other  of  the  tests  for  blood 


690  HEMORRHAGE   FROM   THE    STOMACH. 

in  the  stomach-contents  given  in  chapter  xiii  will  here  become  neces- 
sary. We  recommend  the  modification  of  Van  Deen's  method,  sug- 
gested by  H.  Weber.  And,  secondly,  it  must  be  ascertained  whether 
the  blood  is  really  from  the  stomach,  and  not  from  the  nose,  throat, 
or  the  esophagus.  Here  a  careful  examination  of  the  respiratory 
passages,  of  the  mouth  and  nose,  will  generally  reveal  the  source  of 
the  bleeding.  The  differential  diagnosis  between  hematemesis  and 
hemoptysis  is  given  in  the  chapter  on  Gastric  Ulcer.  In  doubtful 
cases  the  microscope  may  reveal  tubercle  bacilli  in  case  the  hemor- 
rhage came  from  the  lungs. 

The  differential  diagnosis  between  these  two  causative  conditions 
presents  difficulties  when  there  are  indications  of  pulmonary  tuber- 
culosis simultaneously  with  those  of  gastric  ulcer.  Hemorrhages 
that  come  from  the  esophagus,  especially  the  lower  portion  of  it,  can 
hardly  be  distinguished  from  genuine  gastric  hemorrhages.  Several 
cases  have  been  reported  of  fatal  hemorrhage  from  varices  of  the 
esophagus,  and  the  esophagoscope  has  been  suggested  as  a  means  for 
differential  diagnosis.  In  recent  hemorrhages  from  the  stomach  and 
esophagus,  however,  the  use  of  so  rigid  and  annoying  an  instrument 
to  the  patient  as  the  esophagoscope  is  unjustifiable.  A  microscopic 
examination  of  vomited  matter  may  often  reveal  intact  red  blood- 
corpuscles,  making  the  diagnosis  definite.  It  has  been  suggested  that 
in  hemorrhages  from  the  esophagus  the  blood,  as  a  rule,  is  not  mixed 
with  food  remnants;  but  in  stenosis  of  the  esophagus  the  ingesta 
accumulates  above  the  constriction,  and  ma}^  therefore  be  vomited 
up  mixed  with  blood ;  but  the  food  in  esophageal  vomiting  is  alkaline, 
undigested,  mixed  with  muCus,  saliva,  and  perhaps  blood;  food 
brought  up  from  the  stomach  is  more  or  less  digested,  has  an  acid 
reaction,  and  contains  products  of  peptic  digestion.  Vomiting  of 
blood  occurs  in  about  fifty  per  cent,  of  all  cases  of  gastric  ulcer.  The 
next  most  frequent  cause  is  carcinoma.  But  there  is  a  variety  of  other 
abnormal  conditions  of  the  stomach  which  may  bring  forth  this 
symptom;  these  are:  (i)  Acute  and  chronic  gastritis.  Tissier  re- 
ported a  case  of  an  alcoholic  subject  suffering  from  chronic  gastritis 
who  showed  frequent  vomiting  of  food  and  blood.  The  autopsy 
showed  a  simple  chronic  inflammation  of  the  stomach  with  hyper- 
trophy. (2)  The  gastric  hemorrhages  occurring  periodically  and 
associated  with  abnormal  conditions  in  other  organs.  We  have  con- 
sidered these  possibilities  in  the  etiology.  Da  Costa  mentions  vicari- 
ous gastric  hemorrhage  in  patients  suffering  from  hemorrhoids.  The 
author  has  never  seen  a  case  of  this  sort. 


HEMATEJMESIS   NOT    DUE   TO    ULCER.  69 1 

The  gastric  hemorrhages  that  occur  from  ischemia  due  to  persistent 
vomiting  are  at  times  puzzHng.  During  a  voyage  to  Bremen  in  1896, 
the  author  had  occasion  to  study  a  case  of  this  kind.  A  healthy 
young  man,  age  twenty-two,  suffered  intensely  from  seasickness.  For 
the  first  three  days  he  vomited  everything  he  ate,  and  when  his  stom- 
ach was  empty,  the  nausea  would  continue,  although  nothing  but  a 
little  mucus  was  forced  up,  under  painful  exertions.  On  the  seventh 
day  of  the  voyage  he  vomited  half  a  liter  of  blood,  and  on  the  eighth 
day  about  i^  of  a  liter.  After  that  he  was,  by  the  author's  suggestion, 
kept  constantly  under  narcotics.  The  hypodermic  injections  of 
morphin  proved  most  effective  in  allaying  the  vomiting,  ice-bags 
were  placed  over  the  epigastrium,  and  the  patient's  strength  kept  up 
by  nourishing  enemata.  Although  he  vomited  blood  on  three  other 
occasions  after  that,  the  amount  was  small.  After  our  arrival  in 
Bremen  he  recovered  entirely  and  could  eat  almost  the  regular  hotel 
menu.  This  patient  had  never  previous  to  this  vo)^age  suffered  from 
any  gastric  disease,  and  his  vomiting  of  blood  could  be  attributed 
only  to  the  persistent  emesis  caused  by  the  sea-sickness. 

I  have  observed  a  number  of  cases  similar  to  this  in  hospital  and 
consultation  practice  where  hematemesis  was  brought  on  by  uncon- 
trollable vomiting  of  pregnancy.  One  case  of  death  from  vomiting 
in  pregnancy,  in  which  one  pint  of  blood  was  vomited  the  day  before 
the  fatal  termination,  the  stomach  showed  numerous  hemorrhagic 
infarcts.  Extravasations  of  blood  had  occurred  in  the  submucosa, 
and  under  the  columnar  epithelium,  lifting  it  from  the  glandular 
layer.  The  death  of  this  patient  was  due  to  exhaustion,  because  not 
even  rectal  enemata  could  be  retained,  and  operative  evacuation  of 
the  uterine  cavity  had  been  refused. 

In  chlorotic  and  anemic  patients  that  present  hematemesis  it  is 
wise  to  be  reserved  in  the  diagnosis  of  gastric  ulcer.  In  all  such  cases 
a  careful  blood-count  should  be  made,  and  a  prolonged  course  of  iron 
and  arsenic  undertaken  before  the  diagnosis  of  gastric  ulcer  should  be 
determined  upon.     The  diet  of  such  cases  should  be  that  of  ulcer. 

The  following  is  an  example  of  how  puzzling  cases  of  gastric  hemor- 
rhage may  be  clinically :  A  male  patient  in  the  author's  private  sana- 
torium, had  been  complaining  for  two  years  of  intense  gastric  pains, 
which  recently  had  become  so  aggravated  as  to  cause  refusal  of  food, 
and  consequent  rapid  emaciation.  The  test-meals  showed  a  slight 
excess  of  free  HCl,  equal,  on  the  average,  to  38  degrees,  yL.  normal 

NaOH,     One  morning,  while  the  patient  was  being  examined  by  the 

46 


692  HEMORRHAGE   FROM   THE   STOMACH. 

author,  he  began  to  vomit  his  breakfast,  and  after  the  food  had  all 
been  evacuated,  about  one  pint  of  pure  blood  was  vomited.  The  pain 
in  the  epigastrium  was  somewhat  more  severe  for  several  days  after 
this  attack,  and  on  this  account  an  exploratory  laparotomy  was  ad- 
vised. At  the  operation,  which  was  done  by  Dr.  J.  M.  T.  Finney,  the 
stomach  was  found  entirely  normal,  it  was  not  enlarged,  presented  no 
abnormalities  of  any  kind.  There  were  a  number  of  enlarged  mesen- 
tery glands,  one  of  which  was  excised  by  the  surgeon,  but  on  histologi- 
cal examination  it  showed  nothing  characteristic.  The  patient  re- 
covered from  the  laparotomy,  and  under  a  very  carefully  selected  diet 
and  use  of  external  heat  to  the  epigastrium  with  rest  in  bed  the  pain 
was  cured.  He  was  kept  under  observation  for  six  weeks,  and  dis- 
charged apparently  cured.  Three  months  after  the  operation  he  was 
reported  as  doing  very  well. 

Prognosis. — We  do  not  wish  to  refer  here  to  the  prognosis  of  the 
fundamental  disease  causing  the  hematemesis,  which  is  spoken  of  in 
other  chapters,  but  merely  of  the  hemorrhage  itself.  This  prognosis 
depends  upon  the  quantity  of  the  blood  lost.  The  most  abundant 
hemorrhages  are  observed  in  gastric  ulcer,  but  even  larger  hemor- 
rhages, are,  as  a  rule,  not  dangerous  to  life.  We  have  repeatedly  ob- 
served recovery  from  gastric  hemorrhage  that  had  led  to  collapse  with 
disappearance  of  the  radial  pulse.  The  danger  of  gastric  hemorrhage 
exists  in  an  early  and  rapid  repetition  of  the  loss  of  blood ;  though  we 
have  seen  one  case  of  profuse  gastric  hemorrhage  which  led  to  death 
in  a  very  short  time — we  should  conjecture  about  fifteen  minutes. 

Treatment. — The  treatment  of  this  symptom  has  been  given  under 
the  heading  of  Gastric  Ulcer.  Here  we  wish  to  repeat  once  more  the 
necessity  of  absolute  rest,  of  moral  encouragement  from  the  physician, 
— assuring  his  patient  that  the  symptom  is  entirely  free  from  danger, 
and  will  be  recovered  from, — total  abstention  from  any  food  or  medi- 
cine by  the  stomach,  and  substitution  of  rectal  feeding.  Internal 
medication  during  the  bleeding  is  dangerous.  The  author  favors  a 
hypodermic  injection  of  ergotin  or  ergotol,  of  the  latter  thirty  minims. 
Whenever  there  is  danger  of  collapse  from  very  profuse  loss  of  blood, 
subcutaneous  or  intravenous  injection  of  normal  salt  solution  is 
strongly  recommended.  A  solution  of  0.6  to  0.75  per  cent,  of  sodium 
chlorid  is  used  for  this  purpose.  We  prefer  the  subcutaneous  injec- 
tion to  the  intravenous,  because  it  requires  less  apparatus,  is  rapidly 
executed,  and  free  from  danger.  About  200  c.c.  of  this  salt  solution 
may  be  injected  into  the  subcutaneous  connective  tissue  of  the  breast 


HISTORY  AND   PATHOGENESIS   OF   ENTEROPTOSIS.  693 

in  this  manner,  and  with  the  aid  of  massage  it  is  general!}''  rapidly- 
absorbed.  The  subsequent  treatment  is  that  of  simple  anemia  and  of 
the  causative  condition. 


CHAPTER  IX. 

ENTEROPTOSIS— GASTROPTOSIS. 

CONCERNING  THE   HISTORY   AND    PATHOGENESIS  OF  ENTERO- 
PTOSIS. 

The  term  enteroptosis  comes  from  the  two  Greek  words,  hrzpw^ 
bowel  or  intestine,  and  -ro^friV,  fall.  It  refers  to  a  dislocation  of  the 
abdominal  organs.  Splanchnoptosis  is  a  synonymous  term.  En- 
teroptosis is  a  disease  in  which  the  liver  and  the  kidneys  have  de- 
scended from  their  normal  positions,  and  are  movable.  The  stomach 
is  often  found  descended  and  to  have  assumed  a  vertical  position, 
which  induces  an  atony  of  the  gastric  wall  with  motor  and  secretory 
disturbances.  The  transverse  colon,  particularly  the  hepatic  side  of 
it,  is  found  descended.  Generally  only  one  kidney,  the  right,  is  dis- 
located or  very  movable.  The  terms  hepatoptosis,  nephroptosis, 
gastroptosis,  and  coloptosis  refer  to  the  particular  organ  which  has 
become  displaced.  The  oldest  description  resembling  such  a  clinical 
picture  is  found  in  Aberle's  work  (Z.  c.) ;  and  similar  instructive  ana- 
tomical accounts  are  found  in  the  works  of  Becquet,  Rollet,  Rayer, 
Oppolzer,  and  Chrobak,  referring  to  the  relation  between  hysteria  and 
movable  kidney.  The  causes  assigned  by  these  various  older  writers 
to  the  production  of  movable  kidney  are  manifold,  and  some  of  them 
are  even  at  the  present  time  still  considered  factors  in  the  etiology  of 
enteroptosis ;  one  of  the  earliest  explanations  is  contusion  of  the  renal 
region.  Various  other  traumatisms  are  accused  of  bringing  about 
this  effect;  particularly  severe  coughing  attacks,  such  as  occur  in 
pertussis,  bronchitis,  and  pleurisy,  which  exert  their  pernicious  effect 
especially  when  rapid  emaciation  has  occurred,  as  in  phthisis,  produc- 
ing disappearance  of  the  fat  in  the  adipose  capsule  surrounding  the 
kidney ;  or  when  a  pleuritic  exudate  brings  about  descent  of  the  dia- 
phragm, and  thereby  of  the  liver  and  kidney. 

In  the  opinion  of  Cruveilhier,  Chapotot,  and  Valker  the  corset  is 
an  important  cause  in  the  development  of  this  disease,  and  although 


694  KNT^ROPTOSIS — GASTROPTOSIS. 

Ebstein  denied  this,  Weisker  and  Meinert  have  recently  supported 
this  explanation.  Becquet  considers  that  the  floating  kidney  is  inti- 
mately connected  with  the  sexual  life  of  woman,  and  explains  it  by 
the  congestion  of  the  kidneys  which  occurs  during  menstruation,  as  a 
result  of  the  intimate  connection  between  the  ovarian  and  renal 
plexus.  He  also  associates  the  trouble  with  frequent  births,  uterine 
diseases,  and  pendulous  abdomen.  I  have  seen  a  liver  in  an  autopsy 
on  a  young  woman,  age  twenty-four,  who  died  from  intestinal  per- 
foration in  typhoid  fever,  which  showed  very  marked  grooves  evi- 
dently produced  by  tight  lacing.  The  transverse  colon,  stomach,  and 
the  right  kidney  were  displaced,  and  the  lower  portion  of  the  thorax 
compressed  in  a  funnel-shaped  manner.  Oppolzer  believes  that  rapid 
emaciation  in  wasting  diseases  is  a  cause.  Dietl  has  observed  mova- 
ble kidney  in  four  cases  after  severe  malarial  and  typhoid  fever.  He 
believes  that  in  these  infectious  diseases  marked  change  in  volume  in 
the  abdominal  organs  occurs.  Rollet  argues  in  favor  of  rapid  emacia- 
tion, and  adds  the  pressure  created  by  large  neighboring  organs,  espe- 
cially hepatic  and  splenic  tumors.  He  suggests  the  possibility  of 
inherited  predisposition.  In  experiments  on  cadavers  Heller  could 
not  confirm  the  view  that  traction  made  upon  the  kidneys  by  disloca- 
tions of  the  female  sexual  organs  could  effect  renal  displacement. 

In  1 88 1  Landau  published  a  very  complete  monograph  on  floating 
kidney.  In  explaining  the  etiology  of  the  disease  he  emphasized  three 
factors :  ( i )  Rapid  disappearance  of  the  fat  in  the  adipose  embedding 
of  the  kidney,  and  laxity  of  the  peritoneum.  The  disappearance  of 
the  fat  must  be  rapid,  because  Landau  considered  it  possible  that  an 
accommodation  might  be  effected  through  the  elasticity  of  the  cap- 
sule. (2)  Disease  of  the  abdominal  walls,  which  are  subjected  to 
considerable  changes  in  their  elasticity,  density,  and  resistance  by 
pregnancy  and  abdominal  tumors.  In  rapidly  consecutive  pregnan- 
cies the  condition  known  as  pendulous  abdomen  may  be  developed. 
Normally,  there  is  a  uniform  pressure  on  all  abdominal  organs,  but  in 
cases  of  pendulous  abdomen  this  is  converted  into  the  opposite  condi- 
tion, and  the  intestines  that  hang  into  the  relaxed  abdominal  bag 
exert  a  traction  upon  the  superimposed  organs.  (3)  The  numerous 
displacements  of  the  genitourinary  organs,  which  exert  a  direct  trac- 
tion upon  the  kidneys  by  way  of  the  ureters. 

Among  forty-two  observations  by  Landau,  only  two  were  nulli- 
parae, and  one  of  these  had  been  operated  on  for  an  ovarian  tumor. 

Litten  was  the  first  to  distinguish  between  congenital  and  acquired 


OBSERVATIONS   ON   GASTROPTOSIS.  695 

dislocation  of  the  kidney,  and  also  between  dislocated  kidney  with 
and  without  movability.  His  differentiation  between  a  movable 
kidney  and  a  floating  kidney  that  has  developed  its  own  mesentery 
is  a  masterpiece  of  clinical  diagnosis,  containing  also  a  description  of 
the  possibilities  of  respiratory  movements  that  are  imparted  to  the 
right  kidney,  particularly  by  the  diaphragm  and  the  liver,  thus  ex- 
plaining the  predisposition  of  the  right  kidney  to  abnormal  mova- 
bility. Kuttner  argues  that  a  kidney  that  has  become  loose  in  its 
adipose  capsule  follows  the  movements  of  the  diaphragm  in  a  more 
extensive  manner.  He  explains  the  more  frequent  movability  of  the 
right  kidney  by  assuming  that  the  upper  end  of  this  organ  gradually 
glides  under  the  lower  surface  of  the  liver,  and  is  thereafter  completely 
dislocated  by  the  hepatic  pressure  to  which  the  respiratory  movements 
are  superadded.  James  Israel  first  observed  the  respiratory  move- 
ments of  the  kidney  during  an  operation  in  which  the  lumbar  regions 
had  been  opened.  Bartels  observed  dilation  of  the  stomach  together 
with  movable  kidney,  and  was  one  of  the  first  to  describe  the  simul- 
taneous dislocation  of  several  abdominal  organs.  This  author  and 
his  pupil,  Miiller-Warneck,  advance  a  theory  explaining  the  produc- 
tion of  dilation  of  the  stomach  by  a  floating  kidney : — the  right  kidney 
which  has  become  dislocated,  according  to  their  conception,  presses 
on  the  descending  portion  of  the  duodenum,  which  is  firmly  attached 
to  the  posterior  abdominal  wall  by  the  peritoneum.  The  exit  of  the 
gastric  chyme  is  prevented  by  compression  of  the  duodenum,  and 
gastrectasia  is  the  consequence. 


OBSERVATIONS  ON  GASTROPTOSIS. 

J.  H.  Meckel  first  observed  in  autopsies  the  so-called  vertical  posi- 
tion of  the  stomach,  and  also  that  this  occurred  more  frequently  in 
females,  but  occasionally  also  in  men.  Kussmaul  gave  the  first  clini- 
cal description  of  the  vertical  position  of  the  stomach,  of  which  he 
distinguished  two  kinds, — the  first  was  congenital,  and  represented  an 
arrest  at  a  fetal  stage  of  development,  and  the  second  was  acquired, 
caused  by  the  pressure  of  lacing.  The  movable  pyloric  portion  of  the 
stomach  is  forced  downward  and  toward  the  left  by  the  descending 
liver,-  and  the  cardia  is  held  in  its  position  near  the  median  line. 
Kussmaul  observed  that  a  stomach  of  normal  size  which  had  been 
forced  into  vertical  position  became  displaced  beneath  the  umbilicus. 
This  occurs  when  the  pylorus  is  moved  to  the  left  nearer  the  spinal 


696  ENTKROPTOSIS — GASTROPTOSIS. 

column  while  the  cardiac  portion  with  the  fundus  is  moved  to  the 
right  and  downward.  When  the  car'dia  and  pylorus  are  approxi- 
mated in  this  manner,  the  lesser  curvature  is  converted  into  an  acute 
angle.  The  descending  arm  of  this  angle  becomes  shorter  and  shorter 
while  the  ascending  arm  becomes  longer,  the  stomach  thereby  assum- 
ing the  form  of  an  intestinal  loop,  and  gradually  sinking  below  the 
umbilical  line.  (See  illustration  in  chapter  on  Motor  Insufficiency.) 
In  one  of  the  cases  described  by  Kussmaul  the  wearing  of  the  corset 
was  blamed  for  the  production  of  the  condition,  because  of  very  evi- 
dent and  deep  furrows  on  the  lower  thorax  which  were  undoubtedly 
due  to  lacing. 

A  similar  view  is  held  by  von  ^iemssen,  who  credits  the  so-called 
vertical  position  of  the  stomach  as  being  productive  of  many  ailments 
and  occurring  principally  in  women.  He  believes  the  condition  is 
most  generally  acquired  during  youth  by  excessive  constriction  of  the 
waist  in  lacing.  As  a  consequence  of  this,  the  stomach  can  only 
escape  in  a  downward  direction,  because  the  lacing  compresses  the 
region  of  the  lower  ribs,  and  the  epigastrium  offers  no  space  when  the 
stomach  is  filled  with  food.  The  pyloric  part,  which  is  the  most  mov- 
able, makes  the  most  extensive  excursions,  and  gradually  assumes  the 
lowest  position.  At  the  same  time,  the  duodenum  is  drawn  down 
under  strong  tension  of  the  hepatoduodenal  ligament.  According 
to  Meinert,  the  normal  position  of  the  stomach  in  the  female  sex  is  the 
exception.  According  to  him,  gastroptosis  is  a  drawing  out  of  the 
pyloric  portion  mainly — connected  with  dislocation.  He  does  not 
think  that  it  usually  involves  the  entire  stomach,  and  seeks  its  cause 
in  pathological  changes  of  the  liver,  or  in  the  pyloric  portion  of  the 
stomach  itself.  The  most  frequent  cause,  according  to  Meinert,  is  a 
pathological  change  of  form  of  the  thorax.  When  these  deformities 
of  the  thorax  and  their  causes — such  as  pressure  caused  by  clothing, 
or  peculiarities  of  profession,  and  rachitis — have  influenced  a  series 
of  generations,  they  are,  in  Meinert's  opinion,  capable  of  being  trans- 
planted by  inheritance  upon  both  sexes.  They  are  then  not  congeni- 
tal, but  developmental,  abnormalities. 

Historical   Observations   on  Dislocation   of  the   Colon. — We 

shall  presently  refer  to  Virchow's  contribution  to  our  knowledge  of 
coloptosis,  to  which  he  concedes  great  importance  as  a  primary  factor 
in  the  dislocation  of  the  abdominal  organs.  He  asserts  that  abnor- 
mal flexures  occur  in  the  majority  of  adults,  the  most  frequent  abnor- 


HISTORY    OF    COLON   AND   LIVER    DISLOCATIONS.  697 

mality  being  a  descent  of  the  transverse  colon,  the  next  most  frequent 
being  a  descent  of  the  hepatic  flexure,  and,  lastly,  of  the  splenic 
flexure.  The  simultaneous  existence  of  floating  kidney  and  dislo- 
cated colon  is  described  in  the  autopsy  protocols  of  Sandifort  and 
Aberle.  lycichtenstern  describes  abnormal  position  of  the  colon,  and 
attributes  it  to  abnormal  conditions  of  growth  and  position  dating 
from  the  fetal  period.  He  also  suggests  that  a  defective  development 
of  the  muscular  ligaments  of  the  colon  and  incomplete  descent  of  the 
cecum,  also  abnormally  developed  colon,  and  abnormal  length  of  the 
mesenteries,  are  possible  causes.  Rosenheim  holds  very  similar 
views.  Landau  describes  the  descent  of  the  hepatic  and  splenic 
flexures  of  the  colon  as  quite  constant  accompaniments  of  floating 
kidney. 

Historical  Observations  on  Dislocations  of  the  Liver. — The 
liver  may  become  displaced  in  two  manners — (i)  temporarily,  by 
pressure  from  above,  such  as  is  caused  by  lacing  or  by  pleural  effu- 
sions; (2)  permanent  displacement,  caused  by  disease  of  the  liver 
itself,  increasing  the  volume  of  the  organ,  and  causing  descent  by  its 
augmented  weight.  The  oldest  article  on  dislocation  of  the  liver  is  by 
Cantani,  published  in  1866.  There  is  much  diversity  of  opinion  as  to 
the  frequency  of  dislocated  liver.  Meisner  thinks  the  hepatic  disloca- 
tion is  caused  by  lengthening  of  the  suspensory  ligament  of  the  liver, 
forming  a  peritoneal  fold  analogous  to  that  attached  to  the  right 
hepatic  lobe  in  many  animals,  and  known  as  the  "mesohepar."  The 
direct  cause  of  the  dislocation  he  finds  in  traumatism.  According  to 
Winkler,  the  stretching  of  the  ligament  is  passive  and  secondary ;  the 
first  cause,  in  his  opinion,  being  the  sinking  of  intra-abdominal  pres- 
sure. The  other  causes,  which  are  accentuated  repeatedly,  are  relax- 
ation of  the  abdominal  walls,  physical  overexertion,  repeated  over- 
exertion of  the  abdominal  muscles,  and  rapid  emaciation.  L.  Lan- 
dau holds  that  the  fixation  of  the  liver  is  effected  through  pressure  of 
the  abdominal  muscles  on  the  viscera  and  by  the  elasticity  of  the 
lungs,  which  arch  up  the  diaphragm.  The  so-called  ligaments  of  the 
liver  are  insufficient  to  retain  the  organ  in  position.  The  only  ana- 
tomical attachment  of  importance  is  that  of  the  liver  to  the  inferior 
vena  cava,  by  means  of  the  hepatic  vein.  This  attachment  explains 
why  descent  of  the  organ  as  a  whole  does  not  occur  more  frequently 
than  do  partial  dislocations  of  the  anterior  margin  or  of  the  right 
lobe ;  under  such  conditions  a  partial  rotation  of  the  liver  around  its 
frontal  or  sagittal  axis  occurs. 


698  ENTEROPTOSIS — GASTROPTOSIS. 

To  this  condition  Landau  has  given  the  name  of  "twisted,"  "ro- 
tated," or  "torsion  Hver."  He  has  observed  it  almost  always  in 
connection  with  floating  kidney  and  descent  of  the  transverse  colon, 
a  combination  practically  identical  with  the  clinical  picture  of  en- 
teroptosis. 

Historical  Views  on  General  Enteroptosis. — These  were  the 
views  held  concerning  the  etiology  of  the  dislocations  of  the  various 
abdominal  organs  when  Glenard's  first  publication  appeared  in  1885. 
The  writings  of  Bwald  and  Meinert,  which  have  already  been  quoted, 
were  published  after  those  of  Glenard.  The  ideas  of  the  latter  are 
dwelt  upon  in  another  portion  of  this  article.  For  the  sake  of  con- 
text, it  may  be  repeated  that  a  descent  of  the  right  or  hepatic  flexure 
of  the  colon,  followed  by  dislocation  of  the  transverse  colon,  is  the 
primary  disturbance  in  enteroptosis,  according  to  this  author.  That 
portion  of  the  mesocolon  that  approaches  the  right  flexure  of  the 
colon  he  calls  the  hepatocolic  ligament,  and  considers  that  it  is  na- 
turally very  weak,  and  can  be  loosened  and  stretched  by  the  weight 
of  the  transverse  colon,  particularly  when  this  is  burdened  with  stag- 
nating feces.  The  same  condition  may,  according  to  him,  also  be 
caused  by  exhausting  and  emaciating  diseases,  by  loss  of  tonicity  of 
the  abdominal  muscles,  by  repeated  pregnancies,  by  gastrointestinal 
autointoxication,  by  exhausting  hemorrhage,  or  when  the  abdominal 
muscles  are  permanently  damaged  by  pressure  of  the  clothing. 

When  the  hepatic  flexure  of  the  colon  has  sunk,  the  right,  half  of 
the  transverse  colon  follows,  up  to  the  place  where  it  is  connected 
with  the  pyloric  end  of  the  stomach  by  the  tense  gastrocolic  liga- 
ment; here  the  colon  becomes  kinked,  whereby  stagnation  of  the 
contents  results.  The  colon  becomes  dilated  in  front  of  the  constric- 
tion, but  beyond  this  it  contracts  so  that  it  can  be  felt  as  a  tense  cord. 
After  the  transverse  colon  has  descended,  the  remaining  abdominal 
viscera  follow  as  their  ligaments  become  loosened.  The  stomach  is 
drawn  down  by  the  traction  on  the  gastrocolic  ligament.  Then 
follow  the  liver  and  the  kidneys.  Ewald  has  confirmed  the  obser\^a- 
tions  of  Glenard,  but  he  did  not  confirm  his  views  regarding  the 
primary  factor  in  the  causation  of  the  splanchnoptosis.  The  con- 
tracted portion  of  the  colon  beyond  the  constriction,  which  Glenard 
had  designated  as  the  "corde  colique  transverse,"  is  considered  by 
Ewald  to  be  the  pancreas.  He  also  denies  that  a  simple  kinking  of 
the  colon,  uncomplicated  by  peritonitic  adhesions  or  by  stenosing 
neoplasms,  can  lead  to  stagnation  of  feces.     Similarly  to  authors 


PATHOGENESIS    OF    ENTEROPTOSIS.  699 

previously  quoted,  Ewald  does  not  assign  a  distinct  cause  for  this 
visceral  anomaly,  simply  emphasizing  the  fact  that  long-standing 
dyspepsias  and  bodily  overexertions  may  create  altered  relations  of 
pressure  and  tension,  and  thereby  lead  to  enteroptosis. 

Ebstein,  Litten,  and  Rollet  inclined  to  the  view  that  floating  kid- 
ney was  a  congenital  abnormality.  They  based  their  conclusions 
on  the  presence  of  a  mesonephron.  The  vertical  position  and  de- 
scent of  the  stomach  was  considered  b}^  Kussmaul  a  congenital  ab- 
normality, and  Leichtenstern  held  the  same  view  regarding  displace- 
ment of  the  colon.  Drummond  held  the  opinion  that  a  congenital 
relaxation  of  the  peritoneal  covering  was  the  condition  under  which 
the  kidne)^  became  movable.  Ewald,  I^indner,  and  Kuttner, — com- 
paratively recent  writers  on  the  subject, — realizing  that  all  explana- 
tions made  hitherto  were  more  or  less  hypothetical,  have  inclined  also 
to  the  theory  of  inherited  predisposition;  but  Landau  considers  a 
congenital  predisposition  improbable. 

Although  partial  dislocations  of  individual  viscera,  and  even  of  two 
or  three  of  these  organs  at  the  same  time,  have  been  observed  and 
described  by  other  authors  quoted,  the  first  complete  clinical  repre- 
sentation must  be  credited  to  Glenard.  But  one  can  not  fail  to  be 
impressed  with  the  fact  that  the  explanations  of  the  etiology  given  by 
Glenard  himself,  as  well  as  by  writers  antedating  and  succeeding 
him,  are  widely  divergent.  It  is  apparent  from  the  writings  of  these 
authors  that  the  order  of  displacement  and  the  new  abnormal  posi- 
tion of  the  dislocated  organs  are  very  variable.  Throughout  all  of 
these  writings,  however,  there  is  a  general  agreement  that  these  dis- 
locations are  pathological. 

Pathogenesis  of  Enteroptosis. — Most  of  the  hypotheses  pre- 
sented in  the  foregoing  in  explanation  of  the  etiology  of  enteroptosis 
can  not  be  controlled  experimentally.  Glenard's  hypothesis  also 
evades  critical  investigation.  The  view  of  Tandau  that  the  principal 
and  primar}^  cause  is  disease  of  the  abdominal  walls  is  not  applicable 
to  a  large  number  of  cases ;  for  enteroptosis  occurs  in  all  ages,  in  men 
as  well  as  in  women.  Personally,  I  have  observed  two  cases  in  young 
girls,  aged  ten  and  twelve  years  respectively,  and  one  case  in  a  boy 
aged  eleven.  Gastroptosis,  movable  right  kidney,  and  dislocation  of 
the  colon  have  been  observed  in  men  with  strong  abdominal  muscles, 
and  also  in  women  who,  although  the}'  had  given  birth  to  one  child, 
showed  no  relaxation  of  the  abdominal  muscles.  Therefore,  the 
explanation  of  Landau  is  not  universally  applicable.     Meinert's  views 


700  ENTEROPTOSIS — GASTROPTOSIS. 

do  not  explain  the  existence  of  enteroptosis  in  men  and  children,  and, 
in  order  to  escape  from  this  dilemma,  he  conceived  a  theor}-  of  in- 
heritance of  acquired  malformations  of  the  thorax.  Langerhans 
("Archiv  fiir  A^rdauungs-Krankheiten,"  Bd.  iii,  1897)  recognizes 
five  causes,  all  of  which  are  more  or  less  familiar  to  us:  (i)  Relaxa- 
tion of  the  abdominal  muscles;  such  cases  developing  after  child- 
birth he  designates  as  Landau's  enteroptosis.  (2)  Hereditary  en- 
teroptotic  predisposition.  Stiller,  who  adheres  to  this  view  ("Archiv 
fiir  Verdauungs-Krankheiten,"  Bd.  11,  p.  289),  claims  to  have  found  a 
pathognomonic  sign  for  enteroptosis.  This  is  the  fluctuating  tenth  rib, 
which  is  not  firmly  fixed  into  the  cartilaginous  costal  arch,  together 
with  the  sixth,  seventh,  eighth,  and  ninth  ribs,  but  floats,  like  the 
eleventh  and  twelfth.  The  tip  of  the  tenth  rib,  if  it  is  floating,  can 
be  felt  in  the  prolongation  of  the  mammillary  line.  Stiller  asserts 
that  whenever  the  tenth  rib  is  mobile,  there  must  be  a  movable  kid- 
ney and  an  atonic  dilated  stomach.  (This  does  not  mean  gastro- 
ptosis.)  The  reverse  is  not  always  true.  Xot  in  all  cases  of  entero- 
ptosis did  he  find  a  floating  tenth  rib.  He  suggests  that  it  may  be  a 
distinguishing  sign  between  congenital  and  acquired  enteroptosis. 
(3)  The  pressure  of  clothing,  as  tight  belts  and  corsets.  (4)  Chloro- 
sis. These  cases  Langerhans  designates  as  ^^leinert's  enteroptosis. 
(5)  Xervous  dyspepsia.  The  author,  in  accepting  these  five  factors 
mentioned  by  Langerhans  as  undoubtedly  active  in  the  pathogenesis 
of  dislocated  kidney  in  its  various  types,  would  add  the  following : 

(6)  Displacements  of  the  female  genitourinary-  organs,  producing 
traction  upon  the  kidney  by  means  of  the  ureters.  (7)  Curv^atures 
of  the  spine.  (8)  Enlargement  and  increase  in  weight  of  the  organ 
by  neoplasms,  cysts,  etc.,  and,  perhaps,  (9)  traumatism — direct 
violence. 

The  most  recent  contribution  to  the  pathogenesis  of  enteroptosis  is 
by  Joseph  Rosengart  ("Zeitschr.  fiir  diatetische  und  physikalische 
Therapie,"  Bd.  i,  p.  220).  The  views  of  this  author,  which  are  based 
on  sound  anatomical  and  embryological  investigations,  are  the  fol- 
lowing :  Enteroptosis  is  a  disposition  of  the  abdominal  viscera  in  such 
situations  as  are  found  in  the  fetal  organism;  it  is  a  pathological 
reversion  to  an  embryonic  state.  This  arrangement  of  the  viscera, 
which  is  normal  during  fetal  life,  becomes  still  more  developed  during 
the  first  period  of  extrauterine  life :  i.  e.,  for  a  time  after  birth  the  ab- 
dominal organs  are  in  a  more  progressed  state  of  enteroptosis,  from 
which  the  normal  position  of  the  viscera  is  xQvy  gradually  developed. 


REVERSION    TO    EMBRYONIC   STAGE.  70I 

If  an  arrest  of  development  at  a  fetal  stage  or  at  a  stage  of  very  early 
childhood  can  not  be  accepted  as  an  outright  explanation,  neverthe- 
less the  manner  and  order  in  which  the  organs  gradually  rise  into  the 
normal  position  in  the  adult  point  out  the  way  and  the  mechanism  by 
which  enteroptosis  is  developed  from  the  normal  location  of  the  viscera 
after  this  is  once  established.  Rosengart  gives  a  fascinating  account 
of  a  study  of  a  male  fetus  in  the  sixth  month  of  its  history.  The  small 
curvature  of  the  stomach  extends  perpendicularly  up  and  down,  and, 
together  with  the  gastrohepatic  (omentum  minus)  and  the  hepato- 
duodenal ligaments,  is  directed  toward  the  right,  and  anteriorly. 
The  ascending  and  the  transverse  colons  extend  in  a  straight  line 
from  the  right  lower  inguinal  region  diagonally  upward  through  the 
abdomen.  More  than  one-third  of  the  right  kidney  lies  upon  the 
right  iliac  bone ;  the  upper  end  of  the  right  kidney  does  not  reach  so 
high  as  the  left.  The  anterior  surface  of  the  right  kidney  presents 
a  sharp  edge  running  from  the  upper  end  to  the  middle  of  the  outer 
margin  of  the  kidney.  Superiorly  and  exteriorly  to  this  edge  the  kid- 
ney surface  is  flattened,  and  upon  this  portion  rests  the  liver.  The 
lower  portion  of  the  kidney,  extending  downward  and  inward,  is 
pressed  upon  by  the  colon.  The  right  kidney  is  separated  from  the 
spinal  column  by  the  descending  portion  of  the  duodenum.  The 
kidney  is  very  movable  under  the  peritoneum,  which  does  not  cover 
the  entire  anterior  surface  of  the  organ.  In  the  body  of  a  child  four 
weeks  old  the  transverse  colon  was  similarly  found  to  extend  from 
the  lower  right  portion  of  the  inguinal  region  in  a  straight  line 
obliquely  upward.  The  course  of  the  transverse  colon  from  the  right 
inguinal  region  to  the  splenic  flexure  was  a  straight  diagonal;  the 
lesser  gastric  curvature  was  turned  to  the  right  side.  The  left  kidney 
just  touched  the  edge  of  the  iliac  bone  with  its  inferior  end ;  but  more 
than  one-half  of  the  body  of  the  right  kidney  lies  on  the  iliac  bone ;  its 
upper  extremity  does  not  touch  the  beginning  of  the  diaphragm.  The 
position  of  the  stomach,  colon,  liver,  and  kidneys  described  by  Rosen- 
gart corresponds  very  closely  to  the  anatomical  picture  given  by  W. 
Henle  of  the  abdominal  organs  in  the  child  ("Topograph.  Anatomic 
des  Menschen"),  in  which  there  is  complete  vertical  position  of  the 
stomach,  with  corresponding  altered  position  of  the  duodenum,  the 
courses  af  the  ascending  and  transverse  colons  being  merged  into  one 
straight  line ;  the  right  kidney  lying  with  its  upper  half  on  the  quad- 
ratus,  psoas,  and  transverse  muscles,  and  with  its  lower  half  upon  the 
concavity  of  the  iliac  bone.     The  under  surface  of  the  liver,  or,  rather, 


702  ENTEROPTOSIS — GASTROPTOSIS. 

what  becomes  the  under  surface  in  the  adult,  is  turned  completely 
posteriorly.  In  comparing  the  anatomical  observations  on  the  fetus 
and  neonatus  with  the  autopsy  reports  on  cases  of  enteroptosis, — 
such  as  are  presented  by  Ebstein,  Hayem,  Aberle,  Sandifort,  Rayer, 
Schutze,  Legroux,  Danlos,  Cuilleret,  and  L.  Krez, — the  impression 
will  be  gained  that  the  fetal  situation  of  the  organs  had  continued 
unchanged  during  childhood  and  throughout  the  entire  life.  As  has 
already  been  stated,  Kussmaul  regards  the  vertical  position  of  the 
stomach  in  the  adult  as  a  perpetuation  of  a  fetal  condition,  and  my 
observations  on  the  existence  of  gastroptosis  in  young  children  would 
confirm  this  view.  The  arrest  of  any  one  of  the  abdominal  organs  at 
a  stage  of  fetal  development  is  the  condition  necessary  to  create  ptosis. 
As  Rosengart  points  out,  in  order  that  the  right  kidney  shall  reach  its 
correct  position,  and  that  the  ascending  colon  shall  acquire  its  per- 
manent location,  it  is  necessary  for  the  colon  to  pass  in  front  of  and 
over  the  right  kidney.  If  this  is  not  accomplished,  and  the  colon 
remains  in  its  fetal  position,  two  organs  are  already  displaced,  and  in 
a  position  characteristic  of  enteroptosis.  The  embryonic  relation  of 
the  position  of  the  ascending  colon  and  the  right  kidney,  and  the 
peritoneal  attachment  between  the  two,  are  of  great  importance  for 
the  proper  location  of  the  remaining  abdominal  viscera.  A  loose 
attachment  of  the  peritoneum  upon  the  right  kidney,  and  an  imper- 
fect transition  of  the  peritoneum  from  the  kidney  to  the  colon,  with- 
out completely  grasping  and  encircling  the  latter,  offers  the  condition 
necessary  to  pathological  movability  for  the  right  kidney.  By  means 
of  the  gastrocolic  ligament  the  colon  exerts  a  powerful  influence  on 
the  position  of  the  stomach.  Enteroptosis  is  a  much  more  frequent 
condition  in  adults  than  in  children,  which  indicates  that  in  the  major- 
ity of  cases  the  condition  is  acquired  after  the  position  of  the  viscera 
has  approached  that  found  normally  in  the  adult.  But  even  if  that  is 
the  case,  the  primitive  arrangement  in  the  location  of  the  abdominal 
organs  has  an  important  bearing  on  the  later  abnormal  developments. 
In  the  development  of  the  position  of  the  viscera  to  that  of  the 
normal  adult  the  liver  plays  a  most  important  role.  This  organ 
becomes  relatively  smaller  than  is  found  in  the  fetus  and  neonatus. 
In  the  fetus  the  liver  extends  far  below  the  umbilicus,  but  in  the  child 
several  weeks  old  it  extends  only  to  within  ^  of  an  inch  above  the 
umbilicus.  In  the  fetus  the  anterior  free  margin  of  the  liver  is  very 
much  lower  than  the  posterior.  But  in  the  child  a  few  months  old 
this  posterior  margin  of  the  liver  has  descended  still  further,  so  that 


THE   ROLE   OF   THE   LIVER   IN   ENTEROPTOSIS.  703 

it  touches  the  edge  of  the  ilium,  and  has  pushed  the  right  kidney  in 
front  of  it,  on  the  concavity  of  the  iHum.     With  the  beginning  of 
respiration  the  anterior  margin  of  the  liver  begins  to  rise,  and  the  pos- 
terior margin  descends  somewhat  further.     The  posterior  and  lateral 
sections  of  the  diaphragm  are  the  most  muscular  portions,  which  ex- 
plains the  fact  that  the  pressure  exerted  upon  the  liver  by  the  con- 
tracting diaphragm  is  not  uniformly  equal,  not  concentric;  for  the 
greatest  force  is  brought  to  bear  upon  the  liver  from  the  rear  and  from 
the  sides.     This  effects  a  rotation  of  the  liver  around  a  horizontal 
axis,  a  line  which  we  can  imagine  as  extending  from  the  right  lateral 
to  the  left  posterior  hypochondrium,  and  which  runs  very  close  to  the 
anterior  wall  of  the  vena  cava  posteriorly.     This  rotation  of  the  liver 
and  the  diminution  of  its  size  are  accompanied  by  a  rise  of  the  organ ; 
and  the  remaining  abdominal  organs,  which  are  attached  to  it  by 
peritoneal  folds,  gradually  follow.     When  the  liver  has  become  fixed 
in  the  arching  dome  of  the  diaphragm,  it  is  held  in  its  position  partly 
by  the  aspiration  of  the  thorax,  and  partly  by  the  hepatic  veins,  which 
attach  it  to  the  vena  cava.     But  the  most  important  support  comes 
from  pressure  of  the  abdominal  muscles.     In  the  living  being  the  liver 
is  highly  arched  on  its  convex  surface,  and  its  under  surface  is  not 
turned  backward,  but  forward,  and  arched  up  also  in  a  concave  man- 
ner.    This  position  of  the  liver  is  one  of  the  fundamental  conditions 
for  the  proper  retention  of  the  other  viscera  in  normal  situations. 
Whenever  the  liver  is  forced  out  of  its  normal  position, — in  which  it  is 
held  by  the  aspiration  of  the  thorax,  by  its  attachment  to  the  vena 
cava,  arid  by  abdominal  pressure, — whenever  this  organ  transiently 
or  permanently  descends,  its  volume  increases  at  the  same  time,  and 
it  is  no  longer  possible  for  the  pylorus,  the  duodenum,  and  the  colon 
to  remain  in  normal  positions.     The  liver  is  the  central  figure  in  the 
clinical  picture  of  enteroptosis.     Rosengart  and  Glenard  hold  this 
view,  and  Ewald  reluctantly  admits  that  the  liver  can  not  be  ex- 
cluded from  the  etiology.     All  causes  that  press  down  the  liver,— 
whether  they  act  from  the  thoracic  cavity  upon  the  diaphragm,  or 
externally  upon  the  thorax,— all  diseases  and  changes  that  cause 
relaxation  of  the  abdominal  muscles,  all  diseases  in  the  liver  itself 
that  lead  to  its  enlargement  and  descent,  will  eventually  lead  to 
enteroptosis. 

The  force  by  which  the  liver  is  retained  within  the  arching  dome 
of  the  diaphragm  is  a  considerable  one.  Luschka  compares  the  inti- 
mate contact  of  the  two  curved  arches  of  the  diaphragm  and  the  liver 


704  ENTEROPTOSIS — GASTROPTOSIS. 

to  a  great  ball-and-socket  joint,  held  together  by  atmospheric  pres- 
sure, and  capable  of  movement  only  in  the  direction  of  the  two  arched 
contact  surfaces.  The  path  that  the  liver  must  describe  when  it 
descends  from  its  normal  position  is  the  same  that  it  took  when  it 
rose  to  it  from  its  fetal  situation.  In  its  descent  the  liver  goes  through 
the  peculiar  axis-rotation  aheady  described.  The  direction  of  this 
rotation  is  toward  the  anterior  and  inner  portion  of  the  abdomen. 
The  duodenum,  pylorus,  and  hepatic  flexure  of  the  colon  will,  of  neces- 
sity, for  anatomical  reasons,  have  to  descend  with  it.  The  posterior 
lower  edge  of  the  liver  rises  during  this  axial  rotation  and  becomes 
superimposed  on  the  upper  end  of  the  kidney ;  and  if  there  has  been  a 
predisposition  to  abnormal  motility,  or  a  loose  attachment  of  the 
kidney,  it  will  now  become  completely  dislocated.  In  addition  to 
this  factor  in  nephroptosis  another  important  factor  is  found  in  the 
new  position  of  the  ascending  colon,  which  has  to  force  its  way  over 
the  kidney  in  its  descent,  thus  separating  the  latter  organ  from  the 
spinal  column.  According  to  this  view  enteroptosis  may  also  be 
congenital  or  acquired:  (i)  The  congenital  enteroptosis  is  the  per- 
sistence of  the  fetal  situation  of  all  or  of  a  part  of  the  abdominal  vis- 
cera; (2)  acquired  enteroptosis  is  the  gradual  retrograde  develop- 
ment from  the  normal  to  the  congenital  or  fetal  position. 

The  development  of  icterus  in  cases  of  right-sided  nephroptosis 
and  the  frequent  occurrence  of  gall-stones  in  women  shortly  after 
labor  are  explained  by  the  tension  of  the  hepatoduodenal  ligament 
and  by  the  altered  course  of  the  duodenum  caused  thereby  during 
enteroptosis. 

The  author  has  tested  Rosengart's  theory  by  the  dissection  of 
fourteen  cadavers  of  infants — five  born  before  term  (miscarriages) 
and  nine  born  at  full  term.  Some  of  the  dissections  were  carried  on 
by  the  associate  professor  of  anatomy  at  the  University  of  Maryland, 
Dr.  J.  Holmes  Smith.  We  were  enabled  to  confirm  the  positions 
assigned  by  Rosengart  to  the  stomach,  liver,  and  kidney  of  the 
neonatus,  but  all  except  two  of  the  infants  had  a  transverse  colon 
about  one  inch  above  the  umbilicus.  Rosengart  asserts  that  the 
ascending  and  transverse  colons  were  merged  into  one  straight  line, 
ascending  diagonally  from  the  cecum  in  the  right  lower  abdomen 
directly  across  to  the  splenic  flexure,  so  that  there  was  really  no  trans- 
verse colon  in  the  fetus.  Of  the  five  full-term  infants  we  dissected, 
three  had  a  distinct  transverse  colon  and  two  were  as  Rosengart  de- 
scribes (/.  c,  p.  221). 


UPWARD    DISPLACEMENTS.  705 

Peritonitis  of  the  female  sexual  organs,  and  especially  of  their 
appendages,  comes  under  consideration  in  connection  with  disloca- 
tion of  the  transverse  colon  and  of  the  stomach.  In  almost  all  adults 
partial  states  of  dislocation  of  the  viscera,  and  especially  of  the  intes- 
tines, occur  so  frequently  that  more  persons  have  this  displacement 
than  a  normal  location  of  the  intestines  (Virchow,  /.  c).  The  French 
authors  are  justified  in  assuming  the  great  frequency  of  these  disloca- 
tions. Undoubtedly,  the  majority  of  all  civilized  peoples  have  a  cer- 
tain deviation  in  the  location  of  their  intestines,  or,  in  other  words, 
some  slight  degree  of  enteroptosis.  While  it  is  undoubtedly  true  that 
the  majority  of  these  dislocations  are  due  to  sinking,  nevertheless  the 
contrary  is  also  found.  There  are  also  dislocations  that  move  upward, 
in  which,  for  instance,  the  splenic  flexure  (flexura  linealis)  comes  to  a 
position  above  the  spleen  immediately  next  to  the  diaphragm;  and 
others  in  which  the  hepatic  flexure  moves  upward  far  under  the  liver. 
This  upward  distortion  of  the  intestines  should  also  receive  careful 
consideration.  It  is  evident,  however,  that  every  decided  change  in 
situation  of  this  sort — especially  if  it  is  at  the  same  time  accompanied 
by  kinking,  or  if  considerable  deviation  in  the  direction  of  the  intes- 
tines occurs — must  bring  about  an  interference  with  the  passage 
of  the  contents  of  the  intestines ;  and,  therefore,  nothing  is  more  fre- 
quent than  to  find,  at  the  necropsy,  collections  of  fecal  matter  just  at 
these  angles  and  flexures,  or  that  accumulations  of  gases  occur,  while 
adjacent  parts  of  the  intestines  are  contracted.  Thus  we  get  a  pic- 
ture in  which  spastically  contracted  parts  of  the  intestines  alternate 
with  much  dilated  portions.  The  colon  is  the  main  seat  of  this  diffi- 
culty, and  the  dislocation  occurring  most  frequently  is  a  lowering  of 
the  transverse  colon,  which  often  sinks  under  the  navel,  and  some- 
times even  to  the  true  pelvis,  and  then  forms  a  V-shaped  loop,  or  one 
with  two  parallel  legs.  The  next  most  frequent  point  is  the  sigmoid 
flexure,  which  may  show  all  the  possible  varieties  of  descents  and  dis- 
placement toward  the  right.  The  two  large  flexures  in  the  upper 
part  of  the  abdomen — the  hepatic  and  the  splenic — are  third  in  the 
order  of  frequency  of  dislocations.  The  cecum  may  also  be  drawn 
into  similar  displacements,  and  may  sometimes  move  under  the  liver, 
and  at  other  times  sink  down  into  the  true  pelvis.  These  states  are 
relatively  frequent,  although  little  attention  has  been  given  to  these 
very  chronic  conditions,  because  in  life  it  is  not  known  to  what  extent 
certain  symptoms  are  connected  with  them,  and,  as  a  rule,  no  one 
dies  from  these  displacements. 


7o6  ENTEROPTOSIS — GASTROPTOSIS. 

In  a  treatise  by  Virchow  ("Virchow's  Archiv,"  Bd.  v)  it  was  dis- 
tinctly proved  that  anomalous  adhesions  frequently  occur  simul- 
taneousl}^  with  these  states;  for  instance,  growing  together  of  the 
intestines  with  each  other — that  is,  of  the  various  curves  and  loops 
among  themselves — and  at  other  times  with  the  adjacent  organs. 
The  hepatic  flexure  of  the  colon  to  a  great  extent  becomes  connected 
with  the  gall-bladder  and  the  whole  apparatus  of  the  evacuating 
gall-passages  (see  our  illustrations  of  similar  adhesions,  plate  XV)  ; 
and,  on  the  other  hand,  the  splenic  flexure  comes  into  close  connec- 
tion with  the  spleen  and  the  diaphragm,  and  the  iliac  flexure  with  the 
sexual  organs,  especially  in  women.  These  reciprocal  relations  un- 
doubtedly produce  pulling  of  the  various  parts  among  one  another. 

The  relation  of  partial  peritonitis  to  visceral  dislocations  is  more 
difificult  to  understand,  and  in  this  respect  two  conditions  are  to  be 
distinguished — namely,  a  primary  one,  in  which  peritonitis  occurs 
earlier,  and  a  secondary  one,  in  which,  conversely,  the  peritonitis  is 
caused  by  the  dislocation  and  by  the  other  processes  going  on  within 
the  adherent  part  of  the  intestines. 

Concerning  the  first,  we  have  a  clear  example  in  the  recognized 
cases  of  circumscribed  peritonitis, .  which  are  caused  by  processes 
starting  from  the  gall-bladder  (perihepatitis,  peritonitis  cystica), 
when  adhesions  are  formed  within  the  environment  of  the  gall-pas- 
sages ;  this  is  followed  by  a  shifting  of  the  parts  among  one  another, 
since  the  adhesive  masses  gradually  contract  and  the  retraction  pro- 
ceeds further  and  further.  On  the  other  hand,  secondary  perito- 
nitis is  much  more  difficult  to  prove  in  cases  in  which  one  is  confronted 
with  the  completed  process;  one  can  only  recognize  it  when  fresh 
processes  still  exist.  These  are  found  chiefly  in  those  cases  when 
inflammation  of  the  mucous  membranes,  extending  to  the  perito- 
neum, causes  a  bending  or  kinking  of  the  intestine. 

Virchow  was  the  first  to  draw  attention  to  the  facts  in  studies  on 
dislocations  with  so-called  diphtheric  dysenter}^,  which  ma}^  appear 
distributed  in  a  variable  manner,  so  that  the  foci  of  inflammation 
are  separated  by  long  stretches  of  normal  mucous  membrane.  Ap- 
parently normal  sections  are  succeeded  by  new  areas  of  very  severe 
disease,  so  that  one  may  distinguish  a  sort  of  interrupted  localization. 
He  suggested  that  the  anomalous  flexure,  just  as  the  normal,  is  in 
itself  a  motive  for  localization,  in  that  it  brings  with  it  a  retardation 
in  the  passage  of  the  contents  of  the  intestines,  which  contain  inju- 
rious substances  that  react  upon  the  mucous  membrane,  and  from 


PERITONITIS  AND   COLITIS   AS   CAUSES.  707 

which  the  irritative  process  is  developed.  It  is  exactly  the  same 
thing  that  we  see  in  stenoses,  where  further  disturbances  arise  above 
the  obstruction,  or  with  incarcerated  hernia,  where  the  inflamma- 
tion develops  in  the  part  of  the  intestine  above  the  incarceration, 
and  sooner  or  later  extends  to  the  peritoneum. 

These  consequences  (secondary  peritonitis)  of  partial  enteroptoses 
due  to  acute  inflammations  are  easily  recognized  ("Arch.  f.  pathol. 
Anat.  u.  Physiol.,"  1871,  lii,  34). 

Enteroptosis  is  not  an  anatomical  process  connected  with  constant 
clinical  symptoms.  On  the  contrary,  the  symptoms  will  probably 
be  manifold,  according  to  the  special  pathological  circumstances  oc- 
curring in  various  cases.  Accordingly,  the  disease  in  each  case  will, 
to  some  degree,  come  under  different  categories,  and  one  may  not 
bring  diphtheric  or  simple  colitis,  developed  in  anomalous  flexures, 
into  the  same  category  as  dislocation  pure  and  simple ;  these  are  two 
very  different  things  (Virchow).  I,  therefore,  do  not  consider  en- 
teroptosis an  entity,  but  prefer  to  divide  it  into  several  groups  of 
diseases  when  it  is  regarded  symptomatologically  and  therapeutically. 
We  are  dealing  here  with  very  common  deviations,  and,  if  we  could 
count  the  cases,  they  would  be  found  to  be  more  frequent  than  the 
normal  state;  the  less  complicated  dislocations  only  from  time  to 
time  become  the  origin  of  severer  symptoms. 

Leshaft  has  shown  that  the  size  and  fullness  of  the  abdominal 
organs,  as  well  as  the  condition  of  the  abdominal  integument,  are  im- 
portant for  the  reciprocal  conduct  and  relation  of  the  intra-abdom- 
inal organs. 

Every  abnormal  fullness  or  increase  in  size  of  one  of  these  organs, 
as  well  as  a  decrease  in  the  power  of  resistance  within  the  compass  of 
the  abdominal  integuments,  will  produce  a  change  in  location — a  sort 
of  ptosis,  in  the  sense  of  Glenard,  It  has  been  proved  that  a  descent 
of  the  transverse  colon,  especially  the  right  flexure,  carries  with  it  a 
lowering  of  the  stomach  and  a  descent  of  the  right  kidney.  It  is  evi- 
dent that  the  transverse  colon  does  not  descend  spontaneously  with- 
out pathological  causes,  so  that  there  can  not  well  be  a  primary  en- 
teroptosis. It  is  caused  by  etiological  factors,  such  as  abnormal 
adhesions,  change  of  contents  (coprostasis),  anomalous  flexures  (Vir- 
chow), tumors,  perpetuation  of ,  or  reversion  to,  a  fetal  condition,  etc., 
by  which  the  transverse  colon  is  pulled  down,  and  with  it,  secondar- 
ily, the  stomach  and  small  intestine,  and  eventually  the  kidney,  espe- 
47 


708        ■       ENTEROPTOSIS — GASTROPTOSIS. 

cially  on  the  right  side.     Therefore  most  enteroptoses  are  of  second- 
ary nature. 

Dislocation  of  the  Kidneys. — In  1887  Litten  first  emphasized 
that  "in  the  anomalies  of  location  of  the  kidney  one  must  sharply 
distinguish  dislocation  and  movability."  Although  both  irregularities 
often  occur  together  and  simultaneously,  there  is  no  organic  neces- 
sity for  the  same;  rather,  both  processes  may  appear  entirely  inde- 
pendent of  each  other,  although  in  many  cases  one  finds  a  dislocated 
and  a  movable  kidney  in  the  same  individual. 

Renal  displacements  may  be  (i)  congenital  or  (2)  acquired.  Con- 
genital displacement  occurs  more  frequently  with  the  left  kidney,  and 
oftener  in  males  than  in  females.  (The  ratio  of  Stern  is  20  :  9.)  It 
rarely  occurs  in  both  kidneys,  except  in  those  cases  in  which  they 
have  grown  together.  These  kidneys  are  found  in  the  pelvis  or  above 
the  promontory  of  the  sacrum,  and  are  often  associated  with  intes- 
tinal and  genito -urinary  abnormalities;  but  as  the  condition  gives 
rise  to  few  symptoms,  it  has  more  of  a  pathological  than  a  clinical 
interest.  The  diagnosis  is  difficult  unless  the  mass  can  be  palpated 
from  the  rectum  or  vagina,  or  unless  fluid  can  be  aspirated  from  it, 
giving  the  reactions  of  urine.  The .  acquired  renal  displacement  is 
(i)  due  to  tumors  in  the  neighborhood  of  the  organ,  or  (2)  due  to 
abnormal  movability,  assigned  to  various  causes  already  mentioned. 
In  both  congenital  and  acquired  displacements  the  abnormally  situ- 
ated kidney  may  be  fixed  or  movable.  Congenital  displacements 
are,  as  a  rule,  fixed;  the  acquired  show  a  variable  movability.  A 
movable  kidney  may  be  (a)  in  a  normal  position  or  (b)  dislocated; 
a  dislocated  kidney  may  be  (a)  movable  or  (b)  fixed.  The  so-called 
floating  kidney  (Wanderniere)  belongs  to  the  second  type,  variety  a; 
it  is  a  dislocated,  movable  kidney. 

According  to  Kuttner,  Litten,  and  Ewald,  four  distinct  phases  or 
degrees  of  nephroptosis  may  be  differentiated  by  palpation:  (i)  A 
respiratory  movability  without  dislocation.  (2)  Respiratory  mova- 
bility with  slight  anterior  dislocation — one-third  to  two-thirds  of 
the  kidney  can  be  palpated;  this  is  termed  a  "dislocation  of  the  first 
degree."  (3)  Respiratory  movability  with  close  approximation  to 
the  anterior  abdominal  wall.  The  kidney  is  palpable  in  its  entirety, 
and  can  be  easily  moved  about;  this  is  termed  a  "dislocation  of  the 
second  degree."  (4)  The  dislocated  kidney  is  firmly  adherent  in 
its  abnormal  position. 

Litten  distinguishes  the  following  relations  concerning  the  location 


MOVABIUTY   AND    DISLOCATION.  709 

and  movability  of  the  kidney :  First,  a  simple  dislocation  of  the  same ; 
this  is  more  frequently  congenital  than  acquired.  The  congenitally 
dislocated  kidney  is  found  more  frequently  on  the  left  than  on  the 
right,  and  with  approximately  equal  frequency  in  men  and  women. 
Often  both  organs  are  dislocated.  Not  taking  into  account  the  most 
frequent  form  of  dislocation, — the  so-called  horseshoe  kidney,  in 
which  both  organs  are  united  into  one, — the  dislocated  kidney  is 
found  either  close  under  the  bifurcation  of  the  aorta,  or  above  the 
promontory  of  the  sacrum,  or,  finally,  above  the  sacro-iliac  synchon- 
drosis. With  the  change  in  location  there  is  almost  always  connected 
an  anomaly  of  the  origin  or  course  of  the  renal  artery,  while  the  supra- 
renal capsule  more  frequently  remains  in  its  place  and  does  not  follow 
the  kidney  to  which  it  belongs.  Congenitally  dislocated  kidneys  are 
almost  always  fixed  in  the  place  of  their  dislocation.  An  exception 
to  this  is  the  movable  horseshoe  kidney. 

Acquired  dislocations  of  the  kidneys  are  chiefly  due  to  pathological 
enlargements  of  neighboring  organs  (spleen,  liver,  pancreas,  supra- 
renal capsule),  and  are  found  higher  or  lower  than  the  normal  and 
nearer  to  or  further  from  the  vertebral  column.  The  pressure  of 
articles  of  clothing  (such  as  corsets,  belts,  girdles,  etc.)  seems  to  have 
considerable  influence,  by  which  the  liver,  and  with  it  the  kidney,  is 
pushed  down.  Consequently,  this  anomaly  of  location  is  found  less 
frequently  left  than  right — more  frequently  in  women  than  in  men. 
By  the  sinking  of  the  liver — e.  g.,  in  consequence  of  hydatid  cysts — 
the  kidneys  may  be  completely  turned  around,  as  a  result  of  which 
one  m&.y  feel  the  inner  edge  with  the  hilus  upward,  the  convex  edge 
downward,  or  pointing  in  some  other  abnormal  direction.  Most 
frequently  in  this  form  of  dislocation  one  finds  the  kidney  pushed 
downward  and  inward :  i.  e.,  toward  the  median  line.  This  form  of 
dislocation  of  the  kidney,  acquired  late  in  life,  may  become  movable ; 
it  is  almost  always  replaceable  if  it  has  not  become  fixed  in  its  new 
location  by  secondary  inflammation. 

While  one  might  describe  the  above-mentioned  forms  as  disloca- 
tion of  the  kidney  with  and  without  movability,  we  now  come  to  the 
forms  in  which  the  movability  plays  the  main  role, — dislocation  of 
the  secondary  kind, — movable  kidneys  with  and  without  dislocation. 
Here  we  have  to  distinguish  two  main  classes:  (i)  the  wandering  or 
floating' kidney ;  (2)  the  movable  kidney. 

The  floating  kidney  is  distinguished  by  the  mesonephron, — a 
mesenteric  fold  fastened  to  the  kidney, — which  generally  consists  of 


7 1 0  ENTEROPTOSIS — GASTROPTOSIS. 

two  plates,  between  which  the  organ  is  held  and  with  which  it  is  sur- 
rounded. The  characteristic  of  this  form  is  not  the  abnormal  posi- 
tion, but  the  ability  to  change  one  abnormal  position  with  others,  to 
reach  extreme  positions,  and  even  to  reach  the  normal  position  again, 
of  itself.  The  presence  of  this  anomaly  is  always  to  be  traced  back  to 
a  congenital  disposition  of  the  peritoneum,  with  consequent  stretch- 
ing of  the  renal  vessels.  Generally,  one  finds  at  the  autopsy  in  these 
cases  that  all  the  folds,  protrusions  of  the  peritoneum  and  mesen- 
teries, are  abnormally  long  and  lax,  and  the  foramen  of  Winslow  is 
very  wide,  corresponding  to  the  laxity  of  the  lesser  omentum  and  the 
duodenal -hepatic  ligament. 

If  one  uses  this  anatomical  arrangement  for  the  classification,  and 
does  not  designate  at  will  every  unusually  mobile  kidney  as  a  "float- 
ing" or  "wandering  kidney,"  as  is  frequently  done  from  a  clinical 
point  of  view,  it  is  evident  that  every  floating  kidney,  in  the  sense 
adopted  by  Litten,  must  be  congenital.  It  will  hardly  be  possible, 
therefore,  during  life  to  distinguish  these  two  processes  from  each 
other;  on  the  other  hand,  there  will  also  be  cases  in  which  a  very 
short  and  tight  mesonephron  will  restrict  the  extent  of  wandering  of 
the  floating  kidney.  A  simultaneous  permanent  dislocation  of  the 
kidney  may  be  present,  but  not  necessarily ;  it  happens,  occasionally, 
that  a  floating  kidney  in  the  course  of  time  becomes  fixed  and  per- 
manent in  any  abnormal  location  by  means  of  perinephritic  processes, 
so  that  in  spite  of  its  mesentery  it  is  no  longer  movable.  Litten  has 
reported  a  considerable  dislocation  in  a  wandering  horseshoe  kidney, 
where  one  portion  of  the  organ  lay  in  the  right  inguinal  region,  while 
the  opposite  part  lay  upon  the  horizontal  ramus  of  the  right  os  pubis. 
The  organ  could  be  pushed  about  within  the  widest  limits,  and  it  also 
moved  spontaneously,  causing  unpleasant  sensations  to  the  patient. 
In  this  intraperitoneal  position  of  the  kidney  the  organ  seems  to  lie 
immediately  under  the  abdominal  integuments,  where  one  can  not 
only  palpate  it,  but  can  sometimes  also  recognize  its  contour  dis- 
tinctly through  the  abdominal  integuments.  Percussion  over  the 
organ  produces  in  these  cases  a  distinct  dullness,  not  a  tympanitic 
sound,  as  in  the  case  with  the  kidney  situated  extraperitoneally. 

The  movable  kidney  is  distinguished  from  the  normal  solely  by  an 
excessive  movability,  which  is  revealed  to  a  greater  or  less  degree 
(not  taking  into  account  the  normal  respiratory  movability)  in 
changes  in  the  position  of  the  body.  Often  this  anomaly  is  acciden- 
tally recognized  in  manipulations  instituted  for  the  examination  of 


ETIOLOGICAL  FACTORS.  7 II 

the  abdomen.  A  dislocation  of  the  kidney  can  and  often  does  exist 
simultaneously  with  the  above-mentioned  condition,  but  it  does  not 
necessarily  have  to  exist.  We  find  the  right  kidney  more  frequently 
movable  than  the  left  (the  proportion  being  15  to  i),  and  the  anomaly 
is  more  frequent  in  women  than  in  men  (the  proportion  being  84  to 
16).  The  degree  of  movability  seems  to  be  chiefly  dependent  upon 
the  varying  laxity  of  the  part  of  the  peritoneum  descending  in  front 
of  the  kidney,  as  well  as  upon  the  abundance  or  absence  of  the  peri- 
nephritic  or  subperitoneal  adipose  tissue  in  the  region  of  the  loins, 
and  the  greater  or  lesser  power  of  resistance  of  the  intra-abdominal 
organs,  including  the  abdominal  integuments. 

One  can  often  feel  the  kidney  so  distinctly  that  it  may  be  palpated 
with  anatomical  exactness,  although  it  lies  extra-peritoneally,  sepa- 
rated from  the  anterior  abdominal  wall  by  intestinal  loops;  conse- 
quently it  gives  forth  a  decided  tympanitic  sound,  although  one  can 
press  it  very  close  to  the  abdominal  wall.  The  degree  of  movability 
is  just  as  variable  as  the  degree  of  dislocation ;  in  most  cases  we  find 
only  slight  dislocations  from  the  normal  position,  downward  and  in- 
ward. In  by  far  the  greater  number  of  cases  this  condition  is  ac- 
quired, especially  in  the  years  between  twenty  and  forty. 

Etiologically,  the  following  factors  seem  to  have  the  greatest  influ- 
ence: The  disappearance  of  the  fat  in  the  adipose  capsule  in  which 
the  kidney  is  held — through  this  the  kidney  becomes  movable  in  this 
capsule;  the  disappearance  of  the  perinephritic  adipose  tissue, 
through  which  the  kidney,  and  also  its  fat  capsule,  are  moved  out  of 
place ;  further,  the  laxity  of  the  peritoneum,  the  increase  in  the  weight 
of  the  liver,  together  with  the  respiratory  displacement  of  the  same, 
prolapse  of  the  uterus  and  of  the  vagina,  neoplasms  and  retroflexions 
of  the  uterus,  herniae,  weakness  and  laxity  of  the  abdominal  walls,  and, 
above  all,  the  much-discussed  enteroptosis.  Also  heavy  lifting, 
coughing,  pressing,  repeated  pregnancies,  vomiting,  as  well  as  trau- 
matism and  violent  agitation,  are  given  as  causes.  One  of  the  most 
frequent  causes  for  the  movability  of  the  right  kidney  seems  to  be 
lacing  with  corsets,  belts,  and  girdles.  Thus,  von  Fischer-Benzon, 
in  his  dissertation  from  the  pathological  institute  at  Kiel,  states  that 
in  twenty-one  cases  of  movable  kidney  there  was  found  in  eleven 
cases  a  furrow  in  the  liver  due  to  lacing. 

By  lacing  a  decided  pressure  is  exerted  upon  the  lower  part  of  the 
thorax,  by  which  this  is  greatly  narrowed  and  the  organs  lying  within 
it  compressed.     The  liver,  being  the  largest  and  least  compressible  of 


712  ENTEROPTOSIS — GASTROPTOSIS. 

these  organs,  will  suffer  especially.  The  liver,  and  the  kidney 
closely  connected  with  it,  are  pushed  down,  and  the  latter  must  par- 
ticipate in  the  respiratory  excursions  of  the  liver. 

The  more  frequent  displacement  of  the  right  kidney  is  partly  ex- 
plained by  the  anatomic  arrangement  of  its  blood  supply.  The  left 
kidney  has  a  shorter  renal  arter}^  and  a  tighter  attachment  to  the 
suprarenal  body,  by  means  of  the  suprarenal  vein,  which  on  the  left 
side  opens  into  the  renal  vein. 

H.  Schmid  (Penzoldt  and  Stintzing's  "Handbuch  d.  Therapie," 
Bd.  VI,  S.  345)  regards  the  renal  vessels  as  the  most  important  at- 
tachments of  the  kidney ;  if  the  vessels  are  abnormally  long,  an  essen- 
tial support  is  lost.  L.  Knapp  {I.  c.)  looks  upon  uterine  displace- 
ments and  consequent  dragging  upon  the  ureters  as  a  frequent  cause. 

Since  the  respirators^  movements  of  the  diaphragm  are  communi- 
cated to  the  kidney,  the  respiratory  movability  of  the  kidney  may  be 
regarded  as  physiological.  The  author,  following  the  observation  of 
James  Israel,  has  convinced  himself  of  this  normal  movabilitj^  at 
operations. 

Method  of  Palpating  the  Kidneys. — The  chances  of  feeling  the  re- 
spirator}^ movability  of  the  right  kidney  will  vary  according  to  the 
relaxation  and  the  degree  of  resistance  of  the  abdominal  integu- 
ments, the  control  and  experience  of  the  patient  in  breathing,  and 
according  to  the  manual  dexterity  of  the  examiner.  It  is  especially 
important  that  the  patient  inspire  deepty ;  this  can  be  learned  easily 
enough  by  practice.  The  knees  and  thighs  of  the  patient  must  be 
flexed.  The  examiner  himself  must  not  cause  any  pain  or  tension  of 
the  abdominal  integuments  by  his  manipulations.  It  will  then  be 
possible  in  many  cases,  by  means  of  the  bimanual  method  of  examina- 
tion, to  feel  the  kidneys,  especially  the  right  one,  as  it  is  more  easily 
palpable.  It  would,  however,  be  entirely  false  to  believe  that  one 
could  prove  the  respirators'  movability  of  the  kidneys  in  females  only, 
and  especially  in  multiparae.  On  the  contrars',  it  may  be  shown  with 
the  greatest  distinctness  in  men  and  girls,  and  even  in  small  children. 
In  bimanual  examination,  in  order  to  feel  the  right  kidney  the  left 
hand  is  placed  immediately  in  the  rear,  under  the  edge  of  the  ribs  on 
the  right  side,  while  the  tips  of  the  fingers  of  the  right  hand,  similarly 
placed  together,  take  the  corresponding  position  at  the  lower  arch  of 
the  ribs  on  the  same  side ;  on  gradual  downward  pressure  one  feels  a 
larger  or  smaller  part  of  the  organ  between  the  fingers  during  deep 
inspiration.     The  deeper  the  inspiration,  the  greater  the  portion  of 


PALPATION    OF    KIDNEYS.  713 

the  kidney  that  becomes  palpable,  until  with  forced  inhalation  one 
may  sometimes  feel  the  whole  organ  pressed  out  under  the  arch  of 
the  ribs,  and  can,  with  the  greatest  distinctness,  examine  it  by  palpa- 
tion between  both  hands.  If  the  fingers  of  both  hands  are  pressed 
together,  the  kidney  escapes  from  the  hands  (this  is  a  characteristic 
sign),  and  the  person  examined  feels  a  slightly  unpleasant  sensation, 
and  sometimes  a  decided  sensation  of  pressure  or  pain,  or  a  distinct 
jerk.  The  difficulties  in  the  way  of  kidney  palpation  have,  in  the 
author's  experience,  been  very  adipose  abdominal  walls,  tightly  con- 
tracted recti  muscles,  fecal  accumulations  in  the  colon,  and,  rarely, 
neoplasms  of  the  gall-bladder  and  colon,  hydatids  of  the  liver,  and 
causes  enlarging  or  lowering  the  liver,  or  separating  a  portion  of  the 
lower  edge  by  a  furrow  due  to  compression. 

With  this  method  of  examination  one  may  get  a  precise  conception 
of  the  size,  consistency,  and  thickness  of  the  organ ;  possibly  of  neo- 
plastic formations,  lobulations,  irregularities,  even  granulations  and 
processes  of  shriveling,  and  especially  of  increase  in  consistency,  size, 
and  diameter.  The  looser  the  abdominal  integuments,  and  the  more 
completely  the  condition  of  enteroptosis  is  developed,  the  more  fa- 
vorable are  the  conditions  for  palpation.  If  the  kidney  can  not  be  pal- 
pated when  the  patient  is  in  the  dorsal  position,  I  have  frequently 
succeeded  in  palpating  it  by  placing  the  patient  on  her  hands  and 
knees  in  bed.  The  examiner  stands  on  the  left  side  of  the  bed  and 
patient,  facing  the  head.  Both  arms  are  passed  around  the  patient's 
body;  the  right  hand  is  inserted  beneath  the  lower  edge  of  the  liver 
while  the  left  seeks  to  meet  it  by  pressure  from  a  point  about  two 
inches  above  the  umbilicus. 

Gastroptosis. — Diseases  of  the  stomach  are  frequently  connected 
with  dislocation  and  movability  of  the  kidney.  •  Ewald  and  others 
are  of  the  opinion,  supported  by  observation  of  numerous  successive 
cases,  that  the  frequency  of  gastrectasia  with  dislocation  of  the  right 
kidney  is  due  to  an  etiological  connection.  The  view  taken  by 
Quincke,  Nothnagel,  and  Leube  is  that  both  pathological  processes 
occur,  indeed,  very  often  side  by  side,  without  any  causal  connection 
necessarily  existing  between  them.  I  have  not  seen  an  undoubted 
case  of  dilation  of  the  stomach  due  to  obstruction  of  the  pylorus  or 
duodenum  by  floating  kidney.  I  have  observ^ed  gastroptosis  and 
nephroptosis  occurring  together  in  numerous  cases — the  combination 
being  due  to  the  same  cause.  The  changes  of  position  (after  descent) 
of  the  stomach  in  consequence  of  so-called  enteroptosis  and  disloca- 


714  ENTEROPTOSIS — GASTROPTOSIS. 

tion  of  the  right  kidney  are  not  the  classic  gastrectasias  that  develop 
in  consequence  of  mechanical  obstructions  at  the  pylorus  (new  forma- 
tions, cicatrices  of  ulcers,  distortions  in  consequence  of  adhesions, 
compression,  obliteration,  kinking,  etc.,  page  231  of  the  "Proceedings 
of  the  German  Congress  for  Internal  Medicine,"  1887),  but  consist  in 
the  insufficiency  of  the  pylorus,  with  deep  location  and  dilation  of  the 
stomach,  because  the  pylorus  and  the  duodenum  frequently  retain  a 
normal  position.  If  one  does  not  take  into  account  the  gastrectasias 
resulting  from  mechanical  causes,  there  still  remains  a  very  large 
number  of  functional  disturbances  of  the  stomach,  which  lead,  further, 
to  insufficiency  of  the  musculature  and  to  dilation  and  low  position  of 
the  organ.     To  this  class  are  assigned : 

1.  Disease  of  the  musculature  of  the  stomach  in  consequence  of 
protracted  chronic  gastritis. 

2.  Excessive  exertion  of  the  stomach  in  consequence  of  excessive 
amounts  of  healthy  food  or  unsuitable  indigestible  food. 

3.  Abnormally  slow  peristalsis  with  retention  of  food,  as  well  as  the 
abnormal  decomposition  of  the  retained  ingesta,  with  excessive  for- 
mation of  gases. 

As  a  result  of  these  various  chronic  pathological  conditions  of  the 
stomach,  each  of  which  singly  forms  only  a  link  in  the  whole  chain,  a 
dilation  of  the  stomach,  with  attenuation  of  the  walls,  finally  de- 
velops, and  later  a  sinking  down  of  the  organ  and  descent  of  the  right 
kidney,  with  abnormal  movability.  The  function  of  the  stomach  is 
seriously  injured  in  many  directions,  especially  the  motor  power, 
which  under  some  circumstances  ceases  entirely. 

In  such  individuals  200  c.c.  of  liquid  food  are  often  found  in  the 
stomach  from  seven  to  eight  hours  after  ingestion.  Such  conditions 
(called  by  the  French  "dyspepsie  des  liquids")  concern  only  liquid 
food,  while  solid  foods  are  digested,  though  much  more  slowly  than 
normally.  It  was  thus  possible  to  effect  a  nearly  normal  digestion  of 
discs  of  albumin  placed  in  the  gastric  juice  pumped  out  of  the  stom- 
ach. These  observations  are  more  intelligible  in  the  light  of  von 
Mering's  experiments  (see  part  first),  according  to  which  it  is  certain 
that  no  absorption  of  water  takes  place  from  the  stomach,  even  nor- 
mally ;  and  for  the  resorption  of  substances  that  can  be  taken  up  by 
the  mucosa,  a  return  secretion  of  liquid  takes  place  from  the  mucosa 
into  the  stomach.  So  that  it  sometimes  happens  that  after  six  or 
eight  hours  more  liquid  is  drawn  out  of  the  stomach  than  was  in- 
gested.    The  digestive  power  varies  in  these  cases  with  the  state  of 


CAUSES   OF  BNTEROPTOSIS.  715 

HCl;  it  may  be  fairly  good,  but  it  may  be  entirely  absent.  There 
are  undoubtedly  cases  of  gastroptosis  in  which  the  dislocated  stomach 
functions  normally. 

The  displacements  of  the  intestines,  which  arise  through  circum- 
scribed peritonitis,  through  obstruction  of  the  feces,  etc.,  were  de- 
scribed by  Virchow  as  early  as  1853.  Glenard  and  Ewald  have  made 
reference  to  the  entirely  uncomplicated,  one  might  say  the  purely 
gastric  and  intestinal,  cases. 

The  suggestion  of  I^andau,  not  to  be  content  with  the  diagnosis  of 
the  movable  kidney,  floating  liver,  and  kinking  of  the  transverse 
colon,  but  to  seek  the  etiological  diagnosis,  in  order  not  to  come  to 
the  incorrect  conclusion  that  we  have  to  do  with  independent  diseases, 
would  be  valuable  if  it  were  easy  of  execution.  In  the  author's 
opinion,  the  etiological  diagnosis  is  difficult,  sometimes  impossible. 
Enteroptoses,  etc.,  are  secondary  states,  and  should,  for  diagnosis 
and  treatment,  be  considered  in  the  same  light  as  roseola  occurring 
with  typhus  or  syphilis,  in  which  one  is  certainly  not  content  to  diag- 
nose roseola  simply,  but  adds  typhus  or  syphilis  with  roseola. 

Causes. — The  diseases  that  cause  a  sinking  of  one  or  more  of  the 
abdominal  organs  are  all  those  which  absolutely  or  relatively  increase 
the  capacity  of  the  abdomen,  and  thus  allow  the  large  intestine, 
fastened  by  the  relatively  long  mesocolon,  to  sink,  according  to  its 
weight.  The  simplest  or  first  degree,  for  instance,  may  be  said  to 
exist  when  we  meet  with  a  light  inguinal,  femoral,  or  umbilical  hernia. 
In  this  case  all  the  intestines  not  in  the  hernial  sac  may  sink,  through 
pulling  and  dragging.  Since  the  portions  of  the  intestines  which 
were  formerly  in  the  peritoneal  cavity  have  come  out,  the  capacity  of 
the  abdomen  has  been  relatively  increased. 

It  is  true,  splanchnoptosis  is  not  a  necessary  consequence  of  large 
ruptures.  When  the  elasticity  and  contracting  power  of  the  abdomi- 
nal integuments  are  very  great,  they  may  counteract  the  increase  in 
volume  by  tonic  contractions.  A  number  of  cases  are  reported  in 
which  almost  all  the  intestines  lay  in  ruptures ;  and  in  spite  of  this, 
the  kidney,  liver,  and  uterus  were  approximately^  in  normal  positions. 
The  abdominal  integuments  were  contracted  tightly  inward  and  were 
concave. 

Of  far  greater  importance  for  the  origin  of  all  kinds  of  enteroptoses 
is  a  second  great  category  of  diseases — namely,  all  wasting  diseases, 
which  produce  a  quick  consumption  of  the  fat  of  the  body,  and  also 
disturbances  in  the  nutrition  of  the  abdominal  integuments.     Thus, 


7l6  ENTEROPTOSIS — GASTROPTOSIS. 

after  typhoid  fever,  scarlet  fever,  and  other  infectious  diseases, 
splanchnoptoses  of  all  kinds,  such  as  dislocation  of  the  kidneys  and  of 
the  liver,  etc.,  have  been  recognized.  It  is  evident  that  the  transverse 
colon  must  be  lowered  also  when  the  liver  and  kidney  can  be  felt  to 
have  descended,  for  the  transverse  colon,  lying  under  these  organs, 
and  connected  with  them  directly  and  indirectly,  can  not  retain  its 
position  under  these  conditions.  To  prove  the  descent  of  the  trans- 
verse colon  in  such  cases,  the  method  of  the  injection  of  air  into  the 
stomach  and  into  the  colon  alternately  (Ewald)  is  not  always  neces- 
sary, nor  the  very  doubtful  direct  palpation  of  the  transverse  colon, 
as  given  by  Glenard. 

Chronic  diseases,  such  as  phthisis,  produce  exactly  the  same  effect 
as  acute  diseases ;  and  Landau  holds  that  primary  nervous  dyspepsia, 
primary  chronic  gastritis,  duodenitis,  etc.,  are  frequently  not  the  re- 
sult of  enteroptosis,  but,  by  means  of  the  disappearance  of  fat  and 
weakening  of  the  abdominal  integuments,  causes  of  it.  Individuals 
may  be  examined  at  one  period  of  indisposition  and  no  sinking  of  the 
liver  and  kidney  can  be  demonstrated,  but  if  they  should  acquire  an 
ulcer  of  the  stomach  or  nervous  dyspepsia,  with  disturbances  of  nutri- 
tion, we  may  be  able  to  show  prolapse  of  the  liver  or  kidney  in  the 
later  course  of  the  disease. 

Among  the  patients  observed  by  us — sufferers  from  disturbances 
of  nutrition,  nervous  dyspepsia,  emaciation,  etc. — in  which  the 
splanchnoptoses  were  demonstrated,  there  were  a  number  of  cases  in 
which  the  disturbances  of  nutrition  caused  the  ptoses,  and  not  the 
reverse.  In  five  cases  the  patients  had  been  closely  examined  re- 
peatedly before,  and  signs  of  enteroptosis  were  discoverable ;  in  later 
years  these  had  become  very  evident. 

Relaxation  of  the  abdominal  muscles,  with  or  without  pendulous 
abdomen,  is  a  frequent  cause  of  splanchnoptosis.  Sinking  of  the 
kidneys  and  liver  develops  in  women  from  whom  large  ovarian  tumors 
or  myomata  have  been  removed  by  laparotomy.  Other  cases  of  pen- 
dulous abdomen  are  acquired  by  repeated  and  rapidly  consecutive 
births,  and  by  unsuitable  treatment  during  and  after  confinement. 

Similarly,  splanchnoptoses  will  appear  in  individuals  who  suffer 
from  ascites,  and  who  have  been  punctured  repeatedly,  and  in  whom 
the  abdominal  muscles  have  finally  become  paretic  on  account  of 
abnormal  fullness  and  distention.  The  typical  form  of  pendulous 
abdomen  does  not  always  arise  in  these  cases.  If  the  support  of  the 
abdominal  viscera,  formed  by  the  abdominal  integuments,  becomes 


STENOSING   OF   INTESTINES.  7 17 

insufificient,  the  intestines  follow  the  law  of  gravitation  and  descend 
the  length  of  their  mesenteries,  the  peritoneal  folds  of  the  liver  and 
kidney  relax  also,  and  these  viscera  descend,  because  one  of  their 
main  supports — nameh^  the  intestinal  mass — has  been  withdrawn. 
That  which  is  principally  and  etiologically  of  prime  importance  in 
these  particular  cases,  therefore,  is  not  the  sinking  of  the  transverse 
colon,  but  disease  of  the  abdominal  integuments. 

There  are  five  places  especially  at  which  stenosing  phenomena  may 
appear  through  temporary  kinking : 

1.  At  the  pyloric  part  of  the  stomach,  or  where  the  duodenum 
passes  over  from  the  superior  horizontal  part  into  the  vertical  por- 
tion, which  is  tightly  joined  to  the  spinal  column. 

2.  At  the  entrance  of  the  jejunum  into  the  duodenum,  at  the  duo- 
denojejunal flexure  (E.  C.  Perry  and  L-  E.  Shaw,  "Diseases  of  the 
Duodenum,"  "Guy's  Hospital  Reports,"  1893,  p.  171). 

3.  At  the  transition  of  the  small  intestine  into  the  fixed  portion  of 
the  cecum. 

4.  At  the  transition  of  the  transverse  colon  into  the  descending 
colon,  which  is  comparatively  tightly  fixed  at  the  posterior  lateral 
abdominal  wall,  and  is  further  attached  high  up  into  the  left  hypo- 
chondrium  by  the  phrenocolic  ligament  (Phoebus).  The  left  flexure 
of  the  colon  normally  forms  a  right  angle,  which,  however,  becomes 
an  acute  angle  in  patients  with  pendulous  abdomen. 

5.  In  some  cases,  when  the  hepatic  flexure  of  the  colon  has  not 
sunk,  stenoses  may  develop  in  it  at  a  corresponding  place,  as  de- 
scribed in  No.  4  (Landau,  on  "Pendulous  Abdomen,"  p.  82,  et  seq.). 

The  floating  kidney  is  to  be  put  semiotically  on  a  level  with  enter- 
optosis;  it  is  not  a  disease  stii  generis. 

The  dangerous  sequences  of  floating  kidney  are  hydronephrosis, 
intermittent  hydronephrosis,  and  incarceration  of  the  kidney  (first 
described  by  Dittl).  This  dangerous  condition  is  largely  ascribable 
to  compression  of  the  renal  veins. 

Diagnosis. — Movable  kidney  may  be  undoubtedly  recognized  in 
all  cases  where  we  can  firmly  grasp  it  between  the  fingers,  and  can  thus 
determine  exactly  its  entire  configuration.  Secondly,  the  diagnosis 
is  comparatively  simple  in  those  cases  when  we  may  not  determine 
the  configuration,  it  is  true,  but  when  we  discern  only  a  smooth,  mov- 
able body,  often  movable  only  within  narrow  limits,  if  we  are  aided 
by  the  instructions  of  the  patient,  that  after  bodily  exertion,  this 
body  was  suddenly  felt.     But  there  are  cases  where  this  information 


7l8  ENTEROPTOSIS — GASTROPTOSIS. 

of  the  patient  is  lacking,  where  we  can  not  make  the  diagnosis  by- 
palpation  with  certainty,  and  here  mistakes  are  possible.  An  error 
which  has  occurred  repeatedly,  according  to  our  experience,  is  to 
mistake  a  small  lower  part  of  the  liver,  separated  from  it  by  a  strong 
furrow  due  to  compression,  which  part,  on  account  of  the  depth  of 
the  furrow,  seems  to  be  movable,  for  a  floating  kidney.  Guttmann 
has  seen  such  cases  repeatedly  in  autopsies,  which  during  life  were 
regarded  as  movable  livers.  Osier  ("Lectures  on  the  Diagnosis  of 
Abdominal  Tumors,"  p.  97)  gives  an  illustration  of  a  tongue-shaped 
prolongation  of  the  anterior  margin  of  the  right  lobe,  with  the  gall- 
bladder projecting  below  it. 

By  means  of  the  bimanual  examination,  which  has  been  described 
in  detail,  we  are,  at  least  in  a  large  number  of  cases,  able  to  feel  the 
lower  end  of  the  right  kidney  during  inspiration.  And  since  abnor- 
mal (extreme)  movability  occurs  most  frequently  with  the  right  kid- 
ney (in  more  than  eighty  per  cent,  of  the  cases),  therefore,  by  finding 
the  right  lower  edge  of  the  kidney  in  bimanual  palpation,  the  error 
of  mistaking  a  portion  of  the  liver  (separated  from  it  by  a  furrow)  for 
the  kidney  should  be  avoidable. 

Proving  by  means  of  percussion  that. the  kidney  is  not  in  the  proper 
place  is  very  unsatisfactory.  It  seems,  indeed,  in  some  cases,  that 
the  dullness  is  less  on  that  side  where  the  kidney  is  wanting,  than  on 
the  opposite  side,  where  the  kidney  is  present.  But  in  most  cases  of 
movable  kidney  there  was  no  difference  in  the  resonance  in  the  region 
of  the  loins  on  either  side.  We  therefore  attach  no  value  to  the 
results  of  percussion  in  the  diagnosis  of  dislocated  kidney,  and  the 
same  opinion  of  the  use  of  percussion  holds  good  in  diseases  of  the 
kidney  in  general.  Only  in  isolated  circumstances  it  may  aid  the 
other  methods  of  examination, — e.  g.,  in  cases  of  great  swelling  of  the 
kidneys, — but  in  most  cases  percussion  of  the  kidneys  is  entirely 
worthless,  and  hence  I  do  not  consider  it  a  diagnostic  method. 

Frequency  of  Dislocated  Kidney. — The  statements  of  various  clini- 
cians concerning  the  frequency  of  floating  kidney  vary  considerably. 
Lindner  stated  that  it  was  the  most  frequent  abnormalit}^  of  the 
female  body,  and  that  one  woman  in  five  to  seven  was  afflicted  with 
the  trouble.  Edebohls  gives  18  per  cent.,  Mathieu  27.1  per  cent., 
Fischer-Benzon  17  to  22  per  cent.,  John  Schmitt  10  per  cent.  (New 
York,  "Medic.  Monatsschrift,"  March,  1891).  Ludwig  Knapp 
("  Wanderniere  bei  Frauen,"  Berlin,  1896)  gives  5  per  cent.     Einhorn 


FREQUENCY   OF   NEPHROPTOSIS.  719 

gives  1. 8 1  per  cent,  for  men  and  20  per  cent,  for  women  ("New  York 
Med.  Record,"  Aug.,  1898). 

As  far  as  our  clinical  material  permits  us  to  judge  (260  examina- 
tions of  females  from  hospital  and  private  practice),  the  rate  for  our 
Baltimore  cases  is  six  per  cent.  The  right  kidney  is  dislocated  more 
frequently  than  the  left,  the  proportion  being  15  to  i,  and  bilateral 
dislocation  was  found  only  once.  This  rate  includes  only  strictly 
dislocated  kidneys,  not  palpable,  nor  even  movable,  kidneys.  Twelve 
cases  in  which  the  organ  could  be  moved  up  and  down  within  a  space 
of  from  I  to  i^  inches  approximately  were  not  included;  they  were 
found  in  females  giving  no  signs  or  symptoms  of  abdominal  disease, 
being  in  the  hospital  for  acute  pulmonary  diseases,  injuries,  and 
throat  inflammations. 

A  fundamental  requisite  in  describing  these  conditions  is  to  dis- 
tinguish precisely  between  (i)  palpable,  (2)  movable,  and  (3)  dislo- 
cated kidneys.  The  last  may  be  (a)  movable — i.  e.,  the  so-called 
floating  kidney — or  (6)  immovable:  i.  e.,  anchored  down  in  its  ab- 
normal position.  (See  classification  on  p.  708.)  Unless  unusually 
adipose  abdominal  walls  or  firmly  contracted  recti  muscles  interpose 
between  the  palpating  fingers  and  the  kidney,  the  latter  should  always 
be  palpable:  i.  e.,  one  should  be  able  to  feel  the  kidney  in  about  fifty 
per  cent,  of  all  cases.  Furthermore,  these  palpable  kidneys  should, 
even  in  the  majority  of  cases,  be  made  out  as  mobile,  for  these  organs, 
especially  the  right  one,  are  normally  mobile  to  a  slight  degree. 
James  Israel  has  observed  the  respiratory  movements  of  the  kidney  in 
a  case  in  which  the  lumbar  regions  had  been  opened.  In  animals 
(dogs)  the  author  has  never  observed  a  movable  kidney  under  nor- 
mal conditions;  this  is  accounted  for  by  the  horizontal  position  of 
the  body.  But  in  human  beings  the  right  kidney  was  slightly  mova- 
ble in  fifty  per  cent,  of  our  cases.  Palpable  and  movable  kidneys,  as 
a  rule,  give  no  symptoms — only  the  various  types  of  dislocated  kid- 
neys are  clinically  important.  Occasionally,  the  kidneys  can  not 
be  palpated  in  highly  nervous  individuals,  because  of  contraction  of 
the  recti;  if  it  is  absolutely  necessary  to  locate  the  kidneys  in  these 
cases,  they  should  be  examined  in  a  warm  bath  or  under  narcosis. 

Dislocated  kidneys  are  such  as  can  be  moved  out  of  their  normal 
position  more — i.  e.,  further — than  any  distance  ascribable  to  the 
normal  respiratory  movability,  and  that  can  exchange  one  abnormal 
position  with  another  or  with  the  normal,  and  that  give  rise  to  abnor- 
mal symptoms,  as  a  rule.     A  kidney  that  is  movable  in  its  adipose 


720  ENTEROPTOSIS — GASTROPTOSIS. 

imbedding  from  one  to  two  inches  is  not  yet  dislocated,  and  s^^mptoms 
due  to  torsion  of  the  ureters  and  vessels  do  not  arise  until  the  mobility 
exceeds  that  limit.  Great  accuracy  and  precision  are  needed  in  the 
use  of  the  terms  palpable,  movable,  dislocated,  and  floating  kidney, 
and  there  must  be  some  consensus  or  agreement  concerning  the  clini- 
cal meaning  of  these  words,  and  some  limit  to  their  significance,  be- 
fore statistics  can  have  any  value.  Up  to  the  present,  this  matter  is 
in  a  state  of  confusion.  The  degrees  of  dislocation  schematically 
given  on  page  708  may  aid  us  in  reaching  an  understanding. 

Bwald's  assertion  of  the  extraordinary  frequency  of  movable  kid- 
ney is  the  more  astonishing  because  in  autopsies  one  does  not  often 
find  movable  kidneys.  Guttmann,  in  reporting  his  experience,  rest- 
ing upon  about  8000  autopsies  at  Berlin,  which  for  the  most  part  he 
himself  noted  down,  stated  that  in  these  autopsies  the  floating  kidney 
was  not  frequent.  His  experience  agrees  with  that  of  the  pathologi- 
cal institute  of  the  Charite,  Berlin.  Landau,  in  his  monograph  on 
the  floating  kidney,  states  that  in  the  Charite  floating  kidneys  were 
found  very  rarely  at  autopsies.  It  may  be  added,  however,  that  in 
a  horizontal  position  the  movable  kidney  sinks  back  to  its  normal 
position,  and  is,  therefore,  liable  to  be  overlooked  in  the  necropsy; 
but  the  movability  must  persist,  and  this  must  attract  attention 
when  the  kidney  is  taken  out.  In  taking  out  the  kidney  an  expe- 
rienced dissector  will  notice  at  once  whether  it  is  normally  fixed  or 
movable,  dislocated,  or  fixed  in  an  abnormal  position.  The  expla- 
nation given  by  Neumann  of  the  scarcity  of  floating  kidne3^s  at  au- 
topsies, that  the  fatty  envelop,  becoming  solidified  after  death,  tends 
to  fix  the  kidney,  is  unsatisfactory.  In  the  first  place,  the  fatty 
envelop,  if  there  is  any  left,  is  not  any  more  solid  after  death,  neces- 
sarily, than  before,  because  rigor  mortis  does  not  affect  the  solidity 
of  fat;  this  is  influenced  only  by  the  temperature  of  the  cadaver. 
But  Oppolzer,  Ebstein,  and  others  assign  loss  of  the  fatty  imbedding 
as  a  cause  of  floating  kidney,  and  any  one  who  has  observed  a  neph- 
rorrhaphy  can  assure  himself  of  the  scarcity  of  fat  about  such  dislo- 
cated organs.  Besides,  it  requires  a  powerful  effort  of  the  imagina- 
tion to  conceive  of  replacement  of  a  kidney  (dislocation  of  the  second 
degree)  that  may  be  as  far  as  ten  inches  away  from  its  normal  posi- 
tion by  solidification  of  a  supposed  fatty  envelop. 

Reversal  of  the  Location  of  the  Viscera  (Situs  viscerum  inversus). — 
In  this  state  the  stomach  lies  normally  on  the  right  side,  the  heart  on 
the  right  side,  the  liver  on  the  left.     The  site  of  all  the  viscera  is  ex- 


SYMPTOMS    OF    GASTROPTOSIS.  72 1 

actly  reversed ;  there  is  a  situs  inversus,  however,  in  which  the  heart 
is  found  in  the  normal  position  at  the  same  time ;  the  location  of  all 
other  organs  is  reversed. 

Vertical  position  of  the  stomach  is  an  anomaly  frequently  associated 
with  atony,  and  is  attributed  to  tight  lacing.  It  becomes  important 
clinically  only  when  the  motor  function  is  interfered  with,  in  which 
case  the  treatment  is  the  same  as  that  for  motor  insufficiency.  The 
diagnosis  of  vertical  stomach  should  present  no  difficulties  when  the 
methods  stated  on  pages  loi  to  114  are  employed. 

Symptoms  of  Gastroptosis. — The  symptoms  are  brought  on  by 
the  gastric  and  intestinal  atony,  by  the  mechanical  disturbances 
caused  by  the  descent  of  the  organ,  and  neurasthenia.  We  have 
obser\"ed  a  number  of  cases  of  gastroptosis  that  presented  no  diges- 
tive symptoms  whatever.  The  dyspeptic  symptoms  that  are  most 
common  are:  pressure,  fullness,  distention,  and  pain  (gastralgia), 
coming  on  at  irregular  inter\"als,  and  independently  of  the  digestive 
act  or  of  the  quality  and  quantity  of  the  food.  A  sensation  of  heat  or 
burning  at  or  below  the  umbilicus  is  at  times  described.  Eructa- 
tions, nausea,  vomiting,  and  pyrosis  may  be  complained  of.  Chronic 
constipation  is  a  typical  accompaniment;  flatulence  and  occasional 
attacks  of  diarrhea  alternate  with  constipation. 

When  there  is  an  evident  coloptosis,  a  very  stubborn  membranous 
dysenterv'  is,  as  a  rule,  present ;  being,  no  doubt,  caused  by  abnormal 
kinking  and  stenosing  flexures  in  the  course  of  the  large  intestine. 

The  quantity  of  the  urine  may  be  very  variable,  and  depends  upon 
the  permeability  of  the  ureters.  Absolute  obliteration  of  the  ureter 
by  kinking  may  produce  oliguria  or  anuria,  which  may  be  followed  by 
profuse  urination  when  the  ureter  becomes  straightened. 

Circulatory  Symptoms. — A  low  blood  pressure  in  the  systemic  ves- 
sels is  characteristic  of  this  disease.  Disturbances  in  the  rh3'thm 
and  rate  of  the  heart-beat  are  common.  Tachycardia  after  evacua- 
tion of  the  bowels  I  have  also  observed  frequently. 

Nervous  Symptoms. — The  typical  clinical  picture  of  aggravated 
neurasthenia  is  frequently  associated  with  these  cases.  The  mani- 
fold pains  complained  of  during  bodily  exertion  are  referable  to  draw- 
ing and  tugging  upon  the  nerv^ous  apparatus  supplying  the  dislocated 
organs.     Intense  lumbago  is  a  most  frequent  sign. 

The  spleenhdiS  been  very  rarely  found  dislocated  in  splanchnoptosis, 
Glenard  having  obser^-ed  splenoptosis  only  twice  in  148  cases. 

Hepatoptosis  can  be  recognized  by  a  lowering  of  the  area  of  hepa- 


722  ENTEROPTOSIS — GASTROPTOSIS. 

tic  dullness.  There  are  several  degrees  of  liver  displacement :  (i)  A 
portion  of  the  liver  projects  beyond  the  arch  of  the  ribs  into  the  abdo- 
men, and  the  upper  border  is  correspondingly  lower.  (2)  The  lower 
portion,  from  ^  to  f ,  of  the  liver  projects  into  the  abdomen ;  the  liver 
dullness  above  the  edge  of  the  ribs  is  reduced  to  a  narrow  zone  or  is 
entirely  absent.  (3)  The  entire  liver  is  located  within  the  lower 
abdomen. 

Coloptosis. — Descent,  displacement,  with  consequent  local  steno- 
sis, and  dilation  of  portions  of  the  colon  can  be  recognized  by  distend- 
ing the  colon  with  air  or  water.  The  air  is  usually  forced  in  through 
a  long  colon  tube  (Langdon)  by  means  of  a  double-bulb  pump,  or 
from  600  c.c.  to  one  liter  of  warm  water  are  gradually  allowed  to  run 
in  under  gentle  pressiu-e.  Normally,  a  distended  area  is  palpable, 
and  even  visible,  two  or  three  inches  above  the  umbilicus;  the  as- 
cending and  descending  colon  can  be  recognized  as  two  arching 
elongated  prominences  about  three  inches  to  each  side  of  the  um- 
bilicus. When  the  colon  is  prolapsed,  the  transverse  portion  is  found 
touching  at  the  symphysis  pubis,  or  even  within  the  pelvis.  I  have 
occasionally  observed  that  a  prolapse  of  the  colon  was  recognizable 
by  the  distention  that  had  occurred  through  gaseous  fermentation, 
and  that  artificial  distention  was  unnecessary.  When  a  prolapsed 
colon  is  distended  with  warm  water,  it  changes  its  position  with  the 
attitude  of  the  patient.  Thus,  a  colon  that  rests  on  the  symphysis 
will  rise  to  its  normal  location  when  the  pelvis  is  elevated  and  the 
thorax  depressed.  If  this  does  not  occur,  the  colon  is  adherent  in  its 
normal  location. 

Idiopathic  dilation  of  the  colon  may  give  rise  to  symptoms  that 
may  cause  confusion  in  differentiating  the  location  of  stomach  and 
colon.  Reginald  H.  Fitz  called  attention  to  the  similarity  in  the 
clinical  histories  of  chronic  phantom  tumor  and  that  of  idiopathic 
dilation  of  the  colon  ("Am.  Jour.  Med.  Sciences,"  Aug.,  1899,  p. 
134).  The  methods  given  will  suffice  to  determine  the  location  and 
capacity  of  the  colon  as  well  as  that  of  the  stomach. 

Electrodiaphany  is  an  available  method  of  diagnosing  the  course 
and  location  of  the  colon.  The  author  has  frequently  used  it  for  that 
purpose  (see  pp.  107  to  114).  The  results  and  conclusions  derived 
therefrom  are  subject  to  the  same  limitations  as  when  the  electro- 
diaphane  is  used  within  the  stomach. 

Gastroptosis  can  occasionally  be  recognized  by  inspection;  the 
methods  described  in  chapter  xi,  pages   101-107,  if  systematically 


course;  of  gastroptosis.  723 

carried  out,  can  leave  no  possible  doubt  regarding  the  existence  of  this 
dislocation.  The  differentiation  between  prolapse  and  dilation  is 
facilitated  by  electrodiaphany.  If  the  stomach  is  dilated,  not  pro- 
lapsed, the  transillumination  area  will  exhibit  respiratory  movabil- 
ity.  Bwald,  Litten,  and  Bartels  assert  that  dilation  of  the  stomach 
frequently  occurg,  with  nephroptosis  or  hepatoptosis ;  this  is  not  con- 
firmed by  Boas.  Myasthenia,  with  overretention  and  stasis  of  in- 
gesta,  is  frequently  observed,  though  not  in  all  cases  of  prolapse  of  the 
stomach.  The  typical  clinical  picture  of  classical  dilation  may  occur 
in  connection  with  gastroptosis.  By  insufflation  and  coating  of  the 
stomach  with  subnitrate  of  bismuth  by  means  of  the  intragastric 
powder-blower  the  size  and  location  of  the  organ  can  be  demon- 
strated by  means  of  the  Rontgen  rays. 

Analysis  of  the  gastric  contents  in  gastroptosis,  though  yielding 
few  practical  aids  to  diagnosis,  is  useful  in  selecting  a  proper  diet. 
The  results  of  such  chemical  analyses  are  variable. 

The  course  of  gastroptosis  is  protracted  and  generally  chronic. 
Great  feebleness,  abnormal  sensations  of  pain  and  compression,  or  of 
cold  and  hot  aurae,  indisposition  to  exertion,  and  faintness  are  among 
the  most  common  symptoms  in  this  most  variable  clinical  picture. 
Severe  disturbances  of  nutrition  and  anemia  unfailingly  appear  as 
the  digestive  distress  continues. 

The  points  of  differentiation  between  falling  of  the  stomach  and 
dilation  and  atony  have  been  considered  in  the  chapters  on  these 
diseases.  The  differential  diagnosis  between  the  symptoms  of  gastro- 
ptosis-and  nervous  dyspepsia  is  difficult,  sometimes  requiring  all  the 
ingenuity  of  an  experienced  diagnostician.  This  is  principally  be- 
cause the  symptoms  of  both  states  are  occasionally  identical,  and 
because  gastroptosis  is  often  associated  with  nervous  dyspepsia.  The 
state  of  the  peristalsis  is  normal  in  nervous  dyspepsia,  but  in  gastro- 
ptosis there  is,  as  a  rule,  a  myasthenia,  with  overretention  of  ingesta. 

Treatment  of  Gastroptosis. — Prophylaxis.— The  frequency  of 
gastroptosis  and  enteroptosis  in  women  demands  that  the  physician 
should  emphatically  oppose  tight  lacing,  or  any  garment  that  con- 
stricts the  waist.  The  dresses  should  be  so  constructed  as  to  be  sup- 
ported from  the^shoulders.  We  have  already  spoken  of  this  under 
the  heading  of  acute  gastritis.  If  possible,  the  modifications  in  dress 
should  be  made  in  accordance  with  the  rules  of  fashion.  It  will  do 
no  good  to  oppose  the  unrestricted  domination  of  this  tyrant  of  the 
female  sex,  Avithout  clear  indications  of  the  benefit  to  be  derived. 
48 


724  KNTEROPTOSIS — GASTROPTOSIS. 

We  have  already  emphasized  the  fact  that  a  properly  constructed 
corset  does  not  necessarily  work  harm,  but  may  eventually  be  useful, 
by  the  support  it  gives  to  the  back  and  breasts.  The  dresses  should, 
however,  be  supported  from  the  shoulders.  It  is  necessary  to  do  this 
before  the  enteroptosis  is  developed. 

The  relaxation  of  the  abdominal  muscles  must  be  prevented  by 
using  well-applied  bandages  after  confinements,  worn  for  several 
months.  The  bowels  must  be  kept  regular.  Massage,  electricity, 
and  cold-water  applications  may  contribute  to  a  vigorous  abdominal 
musculature,  but  the  most  effective  method  of  strengthening  the 
abdominal  muscles  is  by  abdominal  gymnastic  exercise.  (See 
Illoway,   "Constipation.") 

We  will  briefly  describe  two  of  the  most  practical  methods  of  train- 
ing the  abdominal  muscles: 

No.  I. — ^The  patient  places  himself  on  a  couch  or  on  a  blanket 
spread  on  the  floor,  clothed  simply  in  his  underwear ;  the  hands  are 
placed  at  the  sides.  The  exercise  begins  by  slowly  raising  the  limbs 
from  the  couch  to  a  vertical  position  in  the  air,  keeping  them  there 
for  thirty  seconds,  then  very  slowly  letting  them  return  to  the  hori- 
zontal position  of  rest.  The  secret  of  this  manoeuver  is  its  slow  exe- 
cution. With  one  hand  on  the  abdominal  muscles,  the  patient  may 
feel  the  tightening  and  rigidity  that  occur  in  the  act  of  raising  the 
limbs.     This  exercise  should  be  repeated  ten  times. 

No.  2. — The  second  exercise  should  be  carried  out  in  the  following 
manner:  The  patient  places  himself  flat  on  a  blanket  on  the  floor, 
with  his  feet  inserted  under  a  bureau  or  under  a  piece  of  heavy  furni- 
ture of  any  kind;  both  hands  are  placed  at  the  sides.  The  patient 
now  must  slowly  bring  the  trunk  of  his  body  into  an  erect  position, 
and  when  this  has  been  reached,  the  trunk  is  just  as  slowly  replaced 
in  a  prone  position  on  the  floor. 

Both  of  these  exercises  are  quite  similar;  in  No.  i  it  is  the  trunk 
which  is  fixed  and  the  lower  limbs  are  slowly  moved  up  and  down, 
and  in  No.  2  the  lower  limbs  are  fixed  and  the  trunk  is  moved  up 
and  down.  These  exercises  should  be  carried  out  systematically 
and  methodically  ten  times  every  morning  and  evening.  Sandow's 
book  on  training  will  instruct  those  desiring  information  on  this  very 
useful  subject. 

Rapid  emaciation  must  be  avoided.  Physicians  are  nowadays 
frequently  consulted  by  thin  people  desiring  to  get  fat,  and  by  fat 
people  desiring  to  become  thin,   in  the  most  convenient  manner. 


TREATMENT   OF   GASTROPTOSIS.  725 

Rapid  falling-off  and  loss  of  fat,  when  undertaken  as  a  cure  for  obes- 
ity, is  a  hazardous  undertaking.  The  fat  is  lost  not  only  from  the 
trunk  and  extremities,  but  the  internal  organs  are  deprived  of  their 
normal  incasing  and  imbedding  of  fat,  which  constitutes  their  sup- 
port, so  that  treatments  tending  to  reduce  the  weight  of  the  body 
should  be  conducted  only  under  careful  supervision. 

The  Mechanical  Treatment. — The  mechanical  treatment  consists  in 
applying  a  properly  selected  and  adapted  abdominal  bandage.  There 
is  no  one  particular  bandage  that  will  suit  all  cases.  The  bandages 
should  have  their  main  support  and  resting-places  upon  the  crests  of 
the  ilium,  symphysis  pubis,  and  spinal  column.  From  here  the 
strength  of  the  bandage  is  secured  by  broad  pieces  of  metal  or  whale- 
bone inserted  into  the  linen,  leather,  or  rubber  parts  of  the  bandage. 
These  bandages  must  be  measured  to  the  nude  figure,  must  fit  per- 
fectly, and  should  be  worn  day  and  night.  Boas  recommends  the 
bandage  of  Tandau  and  Bardenheuer.  Prolonged  rest  in  a  horizon- 
tal position  on  the  back  favors  restitution  of  the  abdominal  viscera 
to  their  normal  position.  In  cases  of  great  weakness,  therefore,  with 
emaciation,  the  Weir  Mitchell  rest  cure  is  one  of  the  most  effective 
means  of  treatment. 

Constipation  is  best  combated  by  proper  diet.  The  author  recom- 
mends compotes  of  fruit,  such  as  figs,  prunes,  apples,  pears,  plums, 
and  sweet  grapes.  Buttermilk,  kefyr,  and  good  cider  favor  normal 
evacuation.  Sugar  of  milk,  -j  of  an  ounce  three  times  daily,  is  also 
helpful.  The  injection  of  eight  ounces  of  olive  oil  high  up  into  the 
colon  -is  an  excellent  treatment  for  this  symptom  (Kleiner).  As 
gastroptosis  predisposes  to  dilation,  it  may  occur  that  the  foods  are 
retained  an  abnormally  long  time  within  the  stomach.  In  these 
cases  lavage  will  be  indispensable. 

When  the  symptoms  of  atony  and  motor  insufficiency  are  pro- 
nounced, local  intragastric  douches  with  alternating  cold  and  warm 
water  are  very  effective  in  restoring  partial  tonicity  to  the  muscular 
walls.  Turck's  gastric  resuscitator  is  available  for  this  purpose.  The 
temperature  of  the  water  should  be  changed  every  two  or  three 
minutes  by  alternately  connecting  the  stomach-tube  with  hot  and 
cold  reservoir-bottles,  elevated  to  about  the  level  of  the  patient's 
head.  The  tube  is  of  the  return  or  double-current  type,  and  the 
water  does  not  come  in  contact  with  the  mucosa,  but  fl6ws  through 
a  rubber  bag  which  distends  the  stomach  moderately.  (See  Gilles- 
pie, "Modern  Gastric  Methods,"  p.   164.)     Treating  the  abdominal 


726  ENTSROPTOSIS — GASTROPTOSIS. 

muscles  by  massage  and  the  faradic  current  is  of  some  utility  in  pa- 
tients that  are  too  feeble  to  undergo  the  abdominal  gymnastic  train- 
ing. These  means  of  treatment  may  be  applied  also  in  those  cases 
that  have  not  the  will-power  to  persist  in  such  abdominal  gymnas- 
tics; but  electricity  and  massage  can  not  effect  the  permanent  im- 
provement that  results  from  abdominal  gymnastics. 

Floating  kidneys,  according  to  Bachmeier  ("Wien.  med.  Presse," 
1891,  Nos.  19  and  20),  may  be  replaced  best  in  the  following  manner: 
The  patient  occupies  the  dorsal  position  in  bed,  the  physician  taking 
a  chair  facing  the  head  end  of  the  bed ;  both  hands  are  placed  on  the 
right  side  of  the  patient,  under  the  anterior  arch  of  the  ribs ;  if  possi- 
ble, the  kidney  is  grasped  with  the  fingers  of  the  right  hand ;  the  hands 
are  then  pressed  gently  and  firmly  toward  the  posterior  and  superior 
parts  of  the  abdomen.  While  this  pressure  is  exerted,  the  finger- 
tips must  make  constant  shaking  and  trembling  motions.  The  au- 
thor prefers  placing  the  patient  in  a  recumbent  dorsal  position  with 
the  pelvis  very  much  elevated  and  the  chest  and  head  low;  for  ex- 
ample, the  patient  may  sit  upon  the  high  part  or  head-rest  of  a  sofa, 
and  let  the  body  sink  slowly  down  backward  upon  the  couch;  the 
dislocated  kidney  will  then  of  itself  resume  its  normal  location,- — 
provided  it  is  not  adherent, — particularly  if  the  manipulations  just 
described  are  carried  on  at  the  same  time. 

Diet. — In  enteroptosis  and  gastroptosis  the  diet  should  be  as  nour- 
ishing as  possible,  and  adapted  to  the  state  of  motility  and  secretion. 
If  the  condition  of  the  digestive  organs  will  permit,  attempts  should 
be  made  at  increasing  the  adipose  tissue.  Distinct  diseases  of  the 
gastric  mucosa  contraindicate  a  large  food-supply.  Experience  has 
taught  us  that  one  of  the  best  treatments  for  floating  kidney  is  that 
which  causes  an  increased  deposition  of  fat.  Fat  is  best  introduced  in 
diet  in  the  form  of  fresh  butter,  rich  gravies,  and  cream.  For  further 
particulars  of  nourishing  diet  we  refer  to  the  section  on  Dietetics.  In 
the  author's  sanatorium  for  digestive  diseases  the  schedule  on  pages 
251  and  252  has  been  found  useful  in  nephroptosis.  In  a  number  of 
cases  where  fats  in  the  diet  gave  digestive  distress,  I  succeeded  in  in- 
creasing the  body  weight  by  hypodermic  injections  of  sterile  olive  oil. 

Medicinal  Treatment. — The  use  of  medicines  is  sometimes  una- 
voidable for  the  treatment  of  constipation.  My  favorite  remedy  for 
this,  when  it  becomes  necessary,  is  the  fluid  extract  and  the  active 
syrup  of  Cascara  sagrada  (Clinton  Pharm.  Co.),  or  large  colon  irriga- 
tions with  warm  water,   which  will  also  benefit  the  membranous 


LITERATURE    ON   GASTROPTOSIS    AND    ENTEROPTOSIS.  727 

colitis.  When  patients  can  take  it,  the  time-honored  castor  oil  is  a 
good  and  harmless  remed}^,  but  must  not  be  given  when  there  is  gas- 
tric stagnation.  Of  other  laxative  remedies,  I  favor  aloes,  strychnin, 
rhubarb,  magnesia,  senna,  and  podophyllin.  Jalap  and  scammony 
do  not  act  well,  nor  do  the  very  drastic  purgative  waters,  such  as 
the  Hunyadi  Janos  and  Rubinat-Condal.  In  such  rare  cases  as  could 
tolerate  water-drinking  I  have  seen  more  favorable  results  follow  the 
persistent  use  of  Bedford  Magnesia  Springs  water,  which  is  rather 
mild  in  its  purgative  qualities.  On  the  whole,  I  have  observed  no 
permanent  improvement  under  the  use  of  any  mineral  waters. 

Glenard  recommended  magnesium  and  sodium  sulphate  to  combat 
the  effects  of  autointoxication;  but  Boas,  after  a  prolonged  trial  of 
these  remedies,  asserts  that  he  has  observed  detrimental  results  from 
them.  The  author's  formula  for  combating  autointoxication  in 
gastroptosis  is  the  following: 

U.     Betanaphthol  bismuth,   ......         4.0  ^j 

Resorcin  resublim., .         4.0  ^j 

Strychnin,  sulphatis, 0.02  gr.  W 

In  anacidity  (achylia)  dilute  HCl,  ^vj,  should  be  added. 

Elix.  gentianse, 180.0  ^E^h  ^• 

SiG. — One  tablespoonful  three  times  daily. 

In  addition  to  these,  the  salicylate  of  bismuth,  salicylic  acid,  chloro- 
form water,  and  betanaphthol  have  been  recommended.  They  are 
made  more  efficacious  if  combined  with  strychnin  and  an  adapted 
diet.  ■ 

It  is  conceivable  that  methods  of  surgical  procedure  for  replacing 
a  prolapsed  stomach,  by  attaching  it  partly  to  the  diaphragm,  ensi- 
form  cartilage,  and  perhaps  to  the  retroperitoneal  fascia,  in  such  a 
manner  as  to  avoid  kinking  or  stenosis  (gastropexy),  may  prove 
practicable.  This  operation  has  been  recently  described  in  the  fol- 
lowing publications:  Buret,  see  "Rev.  de  Chir.,"  1896,  xvi,  p.  421; 
also  Davis,  "Western  Med.  Rev.,"  Oct.,  1897;  W.  W.  Keen,  "Cart- 
wright  Lectures,"  "Phil.  Med.  Jour.,"  vol.  i,  p.  935. 


LITERATURE  ON  GASTROPTOSIS  AND  ENTEROPTOSIS. 

1.  Aaron,  C.  D.,  "Gastroptosis,"  "Jour.  Amer.  Med.  Assoc,"  1897,  xxiv. 

2.  Adler,  H.,  "Gastroptosis:  A  Clinical  Study,"  "  Maryland  Med.  Jour.," 
Baltimore,  1898,  xxxix. 

3.  Arendt,  "  Ueber  Mastcuren  und  ihre  Anwendung  bei  chronischen  Krank- 
heitenderweiblichen  Se.xualorgane,"  "  Therap.  Monatshefte,"  1892,  Hefti,  S.  9. 


72  8  ENTKROPTOSIS — GASTROPTOSIS. 

4.  V.  Bachmaier,  "  Die  Wanderniere  und  derenmanuelle  Behandlung,  nach 
Thure  Brandt,"  "  Wiener  med.  Presse,"  1892,  Nr.  19  u.  20. 

5.  Bial,  M.,  "  Ueber  die  Beziehung  der  Gastroptose  zu  nervosen  Magen- 
leiden,"  "  Berl.  klin.  Wochenschr.,"  1897,  xxiv. 

6.  Bial,  M.,  "Gastroptose,"  "  Verhandl.   d.  Cong.  f.  innere  Med.,"  Wies- 
baden, 1897,  XV. 

7.  Boas,    "  Ueber   die  Bestimmung  der  Lage  und  Grenzen    des   Magens 
durch  Sondenpalpation,"    "Centralbl.  f.  klin.  Med.,"  1896. 

8.  Bourget,  "Ueber  den  klinischen  Werth  des  Chemismus  des  Magens," 
"  Therap.  Monatshefte,"  1895. 

9.  Chapotot,  "  L'Estomac  et  le  Corset,"  Paris,  1891. 

10.  Cheron,  "  De  I'Enteroptose,"  "Union  Med.,"  20  Dec,  1888. 

11.  Cuilleret,  "  Etude  Clinique  sur  I'Enteroptose  ou  Maladie  de  Glenard," 
"  Gazette  des  Hopit.,"  1888,  et  No.  105.  1889. 

12.  Czerny,  "  Zur  Prophylaxis  des  Hangebauches  der  Frauen,"  "  Centralbl. 
f.  Gynakologie,"  1886. 

13.  Dehio,  "  Zur  physikalischen  Diagnostik  der  mechanischen  Insufficienz 
des  Magens,"  VII.  Congress  f.  innere  Medicin,  1888. 

14.  Dujardin-Beaumetz,  "  Neurasthenia  Gastrique  et  leur  Traitement," 
"  Lemons  de  I'Hopital  Cochin,"  in  the  "  Therapeut.  Gaz.,"  15  Jan.,  1890. 

15.  Edinger,  "  Wanderniere,"  "  Eulenberg's  Real-Encyklop.,"  2.  Aufl.,  xxi. 

16.  Einhorn,  M.,  "  DieGastrodiaphanie,"  "  New  Yorker  med.  Wochenschr.," 
1889. 

17.  Ewald,  "  Ueber  Enteroptose  und  Wanderniere,"  "  Berl.  klin.  Wochen- 
schr.," 1890. 

18.  Fereol,  "  De  I'Enteroptose,"  "  Bulletin  de  la  Societe  Med.  des  Hopitaux," 
5  Janv.,  1887,  et  12  Novembre,  1888. 

19.  V.  Fischer-Benzon,  "  Ein  Beitrag  zur  Anatomie  und  Aetiologie  der  be- 
weglichen  Niere,"  Inaug. -Dissert.,  Kiel,  1887. 

20.  Fleiner,  "  Ueber  die  Behandlung  der  Constipation  und  einiger  Dick- 
darm-Affectionen  mit  grossen  Oelklystieren,"  "  Berl.  klin.  Wochenschr.,''  1893. 

21.  Fleiner,  "  Ueber  die  Beziehungen  der  Form-  und  Lageveranderungen  des 
Magens  und  des  Dickdarms  zu  Functionsstorungen  und  Erkrankungen  dieser 
Organe,"  "  Miinch.  med.  Wochenschr.,"  1895. 

22.  Fromont,  "  Anatomie  de  la  Portion  Abdominale  de  I'lntestin,"  These  de 
Lille,  1890. 

23.  Gegenbaur,  "  Lehrbuch  der  Anatomie  des  Menschen." 

24.  Glenard,  "Application  de  la  Methode  Naturelle  a  I'Analyse  de  la  Dys- 
pepsie  Nerveuse,"  "  Lyon  Med.,"  1885  ;  "  Enteroptose  et  Neurasthenie,"  Soc. 
Medic,  des  Hop.  de  Paris,  1886 ;  "  Expose  Sommaire  du  Traitement  de  I'Ente- 
roptose," "Lyon  Med.,"  1887,  etc. 

25.  Glenard,  "  De  I'Enteroptose,  conference  facite  a  I'hopital  de  Mustapha," 
Alger-Lyon,  Janv.,  1889,  "Presse  med.  Belg.,"  Bruxelles,  1889. 

26.  Hahn,  "Operative  Behandlung  der  beweglichen  Niere  durch  Fixation," 
"Centralbl.  f.  Chirurgie,"  18S1,  No.  29  (Nephrorrhaphy). 

27.  Hasse,  "  Bewegung.  d.  Zwerchfells — Einfluss  derselben  auf  d.  Unter- 
leibsorgane,"  "  Archiv  f.  Anat.  und  Physiol.,"  1886,  S.  185. 

28.  Hertz,  P.,  "  Abnormitaten  in  der  Lage  und  Form  der  Bauchorgane  bei 
dem  erwachsenen  Weibe,"  Berlin,  1894. 


LITERATURE   ON  GASTROPTOSIS   AND   ENTEROPTOSIS.  729 

29.  Hilbert,  "  Ueber  palpable  und  bewegliche  Nieren,"  "  Deutsches  Archiv 
f.  klin.  Med.,"  1893,  Bd.  l. 

30.  Huber,  A.,  "  Beitrag  zur  Kenntniss  der  Enteroptose,"  Sonderabdr.  a.  d. 
"  Correspondenzbl.  f.  Schweizer  Aerzte,"  1895,  Nr.  11. 

31.  Hufschmidt,  "Pathol,  und  Therap.  d.  Enteroptose,"  "Wien.  klin. 
Wochenschr.,"  1892,  Nr.  52,  including  Literature. 

32.  Israel,  "Ueber  die  Palpation  gesunder  und  kranker  Nieren,"  "  Berl. 
klin.  Wochenschr.,"  1889. 

33.  Kelling,  "  Ein  einfaches  Verfahren  zur  Bestimmung  der  Magengrosse 
mittelst  Luft,"  "  Deutsche  med.  Wochenschr.,"  1892. 

34.  Kelling,  "  Physikalische  Untersuchungen  iiber  die  Druckverhaltnisse  in 
der  Bauchhohle,  sowie  iiber  die  Vitalcapacitat  des  Magens,"  Leipzig,  1896. 

35.  Keppler,  "  Die  Wanderniere  und  ihre  chirurgische  Behandlung,"  Ber- 
lin, 1879. 

36.  Knapp,  Ludwig,  "Wanderniere  bei  Frauen,"  Monograph  (Report  from 
Rosthorn's  Clinic  in  Prague),  Berlin,  1896. 

37.  Konig,  G.,  "  Chemische  Zusammensetzung  der  menschlichen  Nah- 
rungs-  und  Genussmittel,"  BerUn,  1889  und  1893. 

38.  Krez,  L.,  "Zur  Frage  der  Enteroptose,"  "  Munch,  med.  Wochenschr.," 
No.  35,  1892. 

39.  Kumpf,  "  Ueber  die  Wanderniere  der  Frauen  und  deren  Behandlung," 
"  Wiener  med.  Blatter,"  1890,  Nr.  14. 

40.  Kussmaul,  "  Die  peristaltische  Unruhe  des  Magens,  nebst  Bemerkungen 
iiber  Tiefstand  und  Erweiterungen  desselben,"  etc.,  "  Volkmann's  Sammlung 
klin.  Vortrage,"  Nr.  181. 

41.  Kuttner,  "Ueber  palpable  Nieren,"  "  Berl.  klin.  Wochenschr.,"  1890. 

42.  Kuttner,  "  Einige  Bemerkungen  zur  elektrischen  Durchleuchtung  des 
Magens,"  "  Berl.  klin.  Wochenschr.,"  1895. 

43.  Kuttner,  L.,  und  Dyer,  "  Ueber  Gastroptose,"  "  Berl.  klin.  Wochenschr.," 
1897,  XXIV. 

44.  Landau,  "  Die  Wanderniere  der  Frauen,"  Berlin,  1881. 

45.  Leo,  "  Diagnostik  der  Krankheiten  der  Bauchorgane,"  2.  Aufl.,  1895. 

46.  Leube,  "  Specielle  Diagnostik  innerer  Krankheiten,"  1891. 

47.  Lindner,  "Ueber  die  Wanderniere  der  Frauen,"  Neuwied,  1888. 

48.  Litten,  "Ueber  den  Zusammenhang  der  Magenerkrankungen  mit  Lage- 
veranderungen  der  rechten  Niere,"  "Verhandl.  des  Congresses  f.  innere 
Medicin,"  vi,  1897;  ferner:  Berl.  med.  Gesellschaft,  Sitzung  vom  19.  Marz, 
1890;  "  Berl.  klin.  Wochenschr.,''  1890,  Nr.  15. 

49.  Luschka,  "  Lage  der  Bauchorgane,"  Atlas,  Karlsruhe,  1873. 

50.  Malbranc,  "  Ein  complicirter  Fall  von  Magenerweiterung,"  "  Berl.  klin. 
Wochenschr.,"  1880,  Nr.  28. 

51.  Martius,  "Ueber  Grosse,  Lage,  und  Beweglichkeit  des  gesunden  und 
kranken  Magens,"  "  Verhandlungen  der  LXVl.  Naturforscherversammlung," 
1894. 

52.  Meinert,  E.,  "  Ueber  einen  bei  gewohnlicher  Chlorose  des  Entwickelungs- 
alters  erscheinenden  konstanten  Befund,"  etc.,  "  Volkmann's  Samml.  klin. 
Vortrage,"  1895.  Nr.  115  u.  116. 

53.  Meinert,  E.,  "Zur  diagnostischen  Verwerthbarkeit  der  Magendurch- 
leuchtung,"  "  Centralbl.  f.  klin.  Med.,"  1895. 


730  ENTEROPTOSIS — GASTROPTOSIS. 

54.  Meinert  E.,  "  Ueber  normale  und  pathologische  Lage  des  menschlichen 
Magens  und  ihren  Nachweis,"  "  Centralbl.  f.  innere  Med.,"  1896, 

55.  Meinert,  E.,  "  Zur  Aetiologie  der  Chlorose,"  Wiesbaden,  1894. 

56.  Meltzing,  "  Magendurchleuchtungen,"   "  Zeitschr.  f.  klin.  Med.,"  xxvii. 

57.  Meltzing,  "  Gastroptose  und  Chlorose,"  "  Wiener  med.  Presse,"  1895. 

58.  Moritz,  "  Studien  iiber  die  motorische  Thatigkeit  des  Magens,"  "Zeitschr. 
f.  Biologie,"  xxxir,  Neue  Folge,  xiv. 

59.  Mliller-Warneck,  "Ueber  die  widernatiirliche  Beweglichkeit  der  rechten 
Niere,"  "  Berl.  klin.  Wochenschr.,"  1877. 

60.  Munk  und  Uffelmann,  "  Die  Ernahrung  des  gesunden  und  kranken 
Menschen,"  2.  Aufl.,  Wien  und  Leipzig,  1891. 

61.  Oser,  "Die  Ursachen  der  Magenerweiterung,"  "Wiener  Klinik," 
Januar,  1881. 

62.  Pick,  A.,  "  Magen-  und  Darmkrankheit,"  W^ien,  1895,  pp.  179-188  (35 
bibliographical  references). 

63.  Pourcelot,  "  De  I'Enteroptose,"  "  Union  Med.,"  20  Dec,  1888. 

64.  Putnam,  J.  J.,  "  Case  of  Splanchnoptosis  and  Achylia  Gastrica  with  Mel- 
ancholia," "  Boston  Med.  and  Surg.  Jour.,"  Nov.  17,  1898. 

65.  Reichmann  und  Heryng,  "Ueber  elektjische  Magen- und  Darmdurch- 
leuchtung,"  "  Therap.  iSIonatshefte,"  1892,  S.  128. 

66.  Riegel,  "  Die  Erkrankungen  des  Magens,"  Wien,  1896. 

67.  Runeberg,  "Ueber  die  kiinstliche  Aufblahung  des  Magens  und  des 
Dickdarms  durch  Luft,"  "  Deutsch.  Archiv  f.  klin.  Med.,"  1884,  Bd.  xxxiv. 

68.  Shultz,  E.,  "Wanderniere  und  Magenerweiterung,"  "  Prager  med. 
Wochenschr.,"  14.  Januar,  1885. 

69.  Stiller,  B.,  "  Enteroptose  im  Lichte  eines  neuen  Stigma  neurasthenicum," 
"  Archiv  f.  Verdauungskrankh.,"  Bd.  11,  S.  285. 

70.  Sulzer,  M.,  "  Ueber  Wanderniere  und  deren  Behandlung  durch  Neph- 
rorrhagie,"  "Deutsche  Zeitschr.  f.  Chirurgie,"  1891,  Bd.  xxx,  S.  506.  (This 
article  contains  the  complete  literature  on  the  Pathology  and  Treatment  of 
Floating  Kidney  up  to  that  date.) 

71.  Trastour,  "  Les  Desequilibres  du  Ventre,  Enteroptosiques  et  Dilates," 
"  Semaine  Medic,"  7  Sept.,  1887. 

72.  Volcker,  "  Die  Schadlichkeit  des  Schniirens,"  Dissert.,  Munchen,  1893. 

73.  'Weil,  "  Handbuch  und  Atlas  der  topographischen  Percussion,"  Leipzig, 
1880. 

74.  Weisker,  CI.,  "  Ueber  den  sog.  intra-abdominellen  Druck,"  "Schmidt's 
Jahrbiicher  der  gesammten  Medicin,"  Bd.  ccxix,  S.  227. 


NEUROSES    OF    THE    STOMACH.  73 1 


CHAPTER  X. 

NEUROSES    OF   THE    STOMACH. 

Gastric  neuroses  may  be  classified  as  follows : 
I.  Motor. 
II.  Sensory. 
III.  Secretory. 
Under  each  one  of  these  we  may  distinguish — 

(a)  States  of  excitation. 

(b)  States  of  depression  of  nervous  influences. 

I.  Neuroses  of  Motility,  or  Peristalsis. 
{a)  Irritative  states  : 

(1)  Cramp  of  the  cardia,  or  cardiospasm.  ' 

(2)  Cramp  of  the  pylorus,  or  pyloric  spasm. 

(3)  Cramp  of  the  entire  musculature,  or  gastrospasm. 

(4)  The  peristaltic  unrest  of  Kussmaul. 

(5)  Nervous  eructation. 

(6)  Nervous  vomiting. 
(d)  Depressive  states  : 

(i)  Insufficiency   of    the   cardia,    including    rumination    and 
regurgitation. 

(2)  Insufficiency  or  incontinence  of  the  pylorus. 

(3)  Atony  or   insufficiency  of  the  entire  gastric  musculature 

(gastroplegia). 
II.  Sensory  Neuroses. 

(a)  Irritative  states : 
(i)  Hyperesthesia. 

(2)  Gastralgia. 

(3)  Bulimia  and  polyphagia. 
(d)  Depressive  states  : 

(i)  Acoria. 
(2)  Anorexia, 
III.  Neuroses  of  Secretion. 
{a)  Irritative  states  : 

(i)  Hyperchylia,  hyper-  or  superacidity. 
(2)  Supersecretion  or  gastrosuccorrhea,  gastroxynsis. 
{V)  Depressive  states  : 

(1)  Hypochylia  or  subacidity. 

(2)  Achylia  gastrica  and  anacidity. 
Nervous  Dyspepsia. 

Neurasthenia  Gastrica. 


732  NEUROSES   OF  THE   STOMACH. 

General  Considerations. — All  diseases  of  the  stomach  in  which 
no  pathological  anatomical  change  can  be  demonstrated  in  the  organ 
are  classed  as  neuroses.  Hitherto  we  have  considered  only  diseases 
that  were  based  upon  an  actual  alteration  in  the  structure  of  the 
stomach.  Neuroses,  then,  are  idiopathic  diseases  of  the  gastric 
nerves,  with  absence  of  histological  changes  that  can  be  demonstrated 
in  the  tissues.  The  gastric  nerves  can  be  affected,  it  is  true,  in  the 
course  of  gastritis,  ulcer,  carcinoma,  and  dilation,  by  the  changes  in 
the  deeper  layers  of  the  stomach  brought  about  by  these  diseases.  A 
large  portion  of  the  dyspeptic  disturbances,  as  well  as  of  the  anom- 
alies of  secretion  and  motility,  are  attributable  to  injurious  influences 
exerted  upon  the  nerves  in  the  course  of  these  diseases.  These  nerv- 
ous affections  which  accompany  changes  in  the  gastric  structure  are 
known  as  secondary  symptomatic  nervous  disturbances.  It  is  very 
probable  that  anatomical  changes  may  lie  at  the  foundation  of  many 
neuroses,  but  up  to  the  present  time  they  escape  our  microscopical 
^technic.  For  instance,  in  more  than  half  the  cases  of  hyperacidity 
a  proliferation  of  the  oxyntic  cells,  or  of  the  gland  tubules  as  a 
whole,  has  been  ascertained  by  Hayem,  Einhorn,  Cohnheim,  and 
myself  (Hemmeter,  "Histologic  d.  Magendriisen  bei  Hyperaciditat, " 
"Archiv  f.  Verdauungskrankh.,"  Bd.  iv,  S.  23).  It  is  more  than 
probable,  also,  that  atrophy  is  present  in  from  one-half  to  two-thirds 
of  the  cases  of  achylia  gastrica.  With  further  progress  and  improve- 
ment of  our  methods  of  staining  and  hardening  the  number  of  gastric 
neuroses  will  become  more  and  more  reduced. 

The  histological  changes  in  the  mucosa  accompanying  hyperchylia 
and  achylia  are  not  caused  by  the  nervous  condition,  but  constitute 
a  primary  affection  independent  of  the  neurosis.  This  is  made  prob- 
able by  the  fact  that  proliferation  of  oxyntic  cells  and  of  gland  tubules 
can  be  found  at  the  autopsy,  in  the  stomachs  of  individuals  who  have 
never  shown  any  symptoms  of  nervous  diseases  or  neurasthenia,  and 
also  because  proliferation  has  been  found  in  fragments  of  mucosa 
gained  from  the  wash-water  of  perfectly  normal  individuals  so  far  as 
any  neuropathic  state  was  concerned. 

When  the  gastric  nervous  apparatus  is  the  primary  seat  of  the  dis- 
ease, it  is  called  a  primary  neurosis,  but  when  the  disease  of  the  gas- 
tric nerves  is  reflexly  excited  from  the  central  nervous  system,  or 
from  other  organs,  such  as  the  intestines,  liver,  spleen,  and  kidneys, 
it  is  called  a  secondary  or  reflex  neurosis.  Neuroses  may  cause  sec- 
condary  anatomical  alterations  in  the  stomach — for  instance,  if  an- 


NEUROSES   OF  THE   STOMACH.  733 

acidity  is  associated  with  impaired  motility,  we  may  have  a  gastritis 
develop  from  decomposition  of  a  stagnating  ingesta.  When  hyper- 
acidity, or  supersecretion,  causes  a  persistent  spasm  of  the  pylorus,  a 
dilation  may  result  producing  the  same  symptoms.  Disturbances  of 
the  sensory  nerves  of  the  stomach  may  extend  to  the  bowels,  and 
bring  about  the  so-called  neurasthenia  or  nervous  dyspepsia  of  the 
intestines ;  with  persistent  nervous  atony  of  the  stomach  the  motility 
of  the  intestine  frequently  begins  to  suffer  also.  This,  apparently,  is 
a  direct  extension  of  the  nervous  trouble  to  the  intestines.  In  achy- 
lia  gastrica,  when  the  antiseptic  effect  of  HCl  is  missing,  an  excessive 
putrefaction  of  the  intestinal  contents  with  abundant  formation  of 
gases  is  sometimes  noticed,  so  that  the  intestinal  wall  becomes  very 
much  expanded,  and  an  atony  can  arise  in  this  manner.  It  is  well 
known  that  strong  psychic  impressions  and  emotions  like  anger,  ag- 
gravation, fright,  fear,  and  sadness,  as  well  as  excessive  joy,  can  com- 
pletely suppress  the  appetite.  In  very  excitable  people  these  emo- 
tions may  even  cause  eructation,  nausea,  and  severe  gastralgia. 
These  nervous  disturbances  mend  rapidly,  as  a  rule,  when  the  mind 
has  been  quieted ;  but  when  the  emotional  excitement  was  great,  and 
frequently  repeated  within  a  short  time,  particularly  in  very  excita- 
ble, neuropathic  individuals,  a  lasting  neurosis  may  develop. 

Gastric  neuroses  which  are  the  result  of  functional  or  anatomical 
diseases  of  the  nervous  central  organs,  of  hysteria  and  neurasthenia, 
may  be  so  prominent  that  the  fundamental  disease  may  be  com- 
pletely submerged,  and  be  little  regarded  by  the  patient,  and  is  not 
discovered  by  the  physician  until  after  a  careful  study  of  the  case  has 
been  made.  In  sclerosis  of  the  posterior  columns  of  the  spinal  cord 
(tabes  dorsalis)  a  train  of  gastric  symptoms  has  been  first  described 
by  Charcot  under  the  name  of  "crises  gastriques."  They  are  de- 
scribed as  intense  cramp-like  pains  occurring  suddenly  in  the  midst 
of  comparative  well-being,  and  radiating  toward  the  abdomen  and 
back;  they  are  usually  followed  by  copious  vomiting.  The  vomit  at 
first  consists  of  food,  and  later  of  mucus,  bile,  and  duodenal  secre- 
tions, and  may  occur  several  times  in  the  same  day,  frequently  every 
hour.  These  attacks  appear  and  disappear  very  rapidly,  and  are 
separated  by  long  intervals  of  perfect  freedom  from  gastric  disturb- 
ances. Ewald  emphasizes  that  these  attacks  may  occur  in  tabes  so 
early  in  the  disease  that  the  fundamental  affection  can  not  in  all  be 
diagnosed  because  all  typical  symptoms  are  wanting.  Sensations  of 
a  boring  and  burning  character  and  severe  gastralgia  may  be  present 


734  GASTRIC   NEUROSES. 

in  tabic  patients  years  before  the  spinal  disease  is  recognizable  (Sey- 
mour Basch,  "Arch.  f.  Verdauungskr.,"  Bd.  v,  1899).  In  other 
anatomical  diseases  of  the  nervous  central  organs,  in  myelitis  due 
to  compression,  meningitis,  brain  tumors,  and  after  powerful  con- 
cussions of  the  brain  and  spinal  cord,  nervous  gastric  disturb- 
ances appear.  In  the  progress  of  certain  diseases  of  the  medulla, 
repeated  nausea  and  vomiting  may  be  attributed  to  irritation  of  the 
vomiting  center.  Reflex  neuroses  of  the  stomach  may  occur  from 
disease  of  the  neighboring  organs:  as,  for  instance,  from  the  liver, 
intestines,  bile  passages,  spleen,  and  peritoneum,  as  well  as  from  the 
kidneys,  sexual  organs,  and  heart.  In  biliary  colic  gastric  symptoms 
are  rarely  absent.  We  generally  find  that  gastralgia,  nausea,  vomit- 
ing, eructation,  and  anorexia  are  present  during  the  passage  of  gall- 
stones, and  rapidly  disappear  as  soon  as  the  stone  has  passed  through 
into  the  intestine.  The  gastric  complications  of  cholemia  and  chole- 
lithiasis do  not  disappear  so  rapidly,  because  the  excretion  of  the 
foreign  materials  in  the  blood  of  cholemia,  and  the  correction  of  ana- 
tomical changes  in  cholelithiasis  require  time.  Renal  colic  in  a  similar 
manner  may  cause  dyspeptic  symptoms.  Cases  are  reported  in 
which  the  renal  symptoms  were  so  masked  by  the  gastric  that  the 
diagnosis  of  peptic  ulcer  was  made.  This  may  very  readily  occur 
when  the  nephritic  pains  radiate  toward  the  back  and  shoulders  lik^ 
those  of  ulcers.  Gastric  symptoms  occurring  as  a  sequence  to  uremia 
are  the  result  of  a  direct  or  indirect  irritation  of  the  central  nervous 
organs,  and  also  of  the  gastric  nerves  by  retained  products  of  cata- 
bolism.  In  cases  of  contracted  kidney  with  chronic  uremia  in  my 
clinic  the  patient  suffered  exclusively  from  gastric  symptoms,  but 
test-meals  showed  that  the  motor  and  secretory  functions  were  nor- 
mal, at  times  at  least,  and  that,  therefore,  the  dyspeptic  complaints 
were  disturbances  of  the  sensory  nerves  of  the  stomach.  Diseases 
of  the  sexual  organs,  in  both  sexes,  but  particularly  in  women,  may 
bring  about  reflex  gastric  neurosis.  Kretschy  and  Fleischer  have 
found  that  the  physiological  process  of  menstruation  may  cause  dis- 
turbances of  gastric  function,  which  naturally  are  also  met  with  in  a 
more  exaggerated  form  in  dysmenorrhea,  in  diseases  of  the  uterus  and 
ovaries,  and  during  pregnancy.  Whatever  may  be  the  etiological 
culmination  of  factors  in  vomiting  of  pregnancy,  there  is  no  better 
explanation  offered  up  to  the  present  time  than  that  it  is  a  reflex  neu- 
rosis of  the  stomach  induced  by  the  expansion  of  the  uterus  and  irrita- 
tion of  the  sympathetic  fibers  caused  thereby.     R.  Frommel  (Pen- 


ANATOMY   AND   PHYSIOLOGY    OF    GASTRIC    NERVES.  735 

zoldt  und  Stintzing's  "Handbuch  d.  speciel.  Therap.  innerer  Krank- 
heiten,"  Bd.  iv,  S.  440)  has  obtained  very  good  results  in  this  disease 
with  basic  orexin,  a  medicine  which  acts  mainly  in  nervous  affections, 
and  rarely  in  anatomical  alterations  of  the  stomach. 

Gastric  neuroses  are  much  more  frequently  seen  in  women  than 
in  men.  Women  and  girls  of  the  better  classes  constitute  the  pre- 
vailing number  of  those  affected  with  gastric  neuroses.  The  recog- 
nition of  pure  gastric  neuroses  and  whether  they  exist  as  idiopathic 
independent  diseases,  or  are  in  some  causal  relation  to  a  preexisting 
disease,  like  those  we  have  mentioned,  is  often  a  problem  presenting 
great  difficulties.  The  stomach  is  an  organ  that  is  very  rich  in  nerves, 
and  is  inclosed  in  a  widely  connected  network  of  fibers  which  bring  it 
into  close  connection  with  other  vital  organs. 


ANATOMY  AND  PHYSIOLOGY  OF  GASTRIC  NERVES. 
Concerning  the  anatomy  and  physiology  of  the  gastric  nerves,  we 
may  say  that  the  innervation  of  the  organ  is  carried  out  above  all  by 
the  vagi.  The  left  vagus  spreads  over  the  cardiac  portion  and  the 
lesser  curvature,  and  forms  the  anterior  gastric  plexus  with  fibers 
coming  from  the  abdominal  sympathetic.  The  right  vagus  supplies 
mainly  the  liver,  pancreas,  spleen,  kidney,  and  small  intestine,  and  a 
small  part  of  its  branches  reaches  the  posterior  wall  of  the  stomach. 
Anastomoses  from  the  abdominal  sympathetic  with  branches  of  the 
right  vagus  form  the  posterior  gastric  plexus.  The  vagi  also  enter 
into  the  formation  of  the  celiac  or  solar  plexus.  Branches  from  the 
solar  plexus  form  the  so-called  superior  coronary  plexus  of  the  stom- 
ach lying  along  the  lesser  curvature,  while  branches  coming  from  the 
hepatic  plexus  and  running  along  with  the  right  inferior  coronary 
artery  form  the  inferior  coronary  plexus  of  the  stomach.  These  four 
plexuses  are  united  into  a  great  network  by  connecting  communica- 
tive branches.  In  the  pyloric  portion,  the  beginnings  of  the  large 
and  important  intestinal  plexuses  can  be  demonstrated.  The  intes- 
tinal sympathetic  nerves  form  a  network  with  close  meshes  in  the 
submucosa  as  well  as  in  the  muscular  layer.  In  the  broadened  points 
of  union  of  this  nervous  network  are  found  numerous  ganglion  cells. 
The  Meissner  network  supplies  the  muscularis  mucosae,  and  the  mu- 
soca  and  the  intermuscular  plexus  of  Auerbach  supply  the  muscular 
layers  with  very  fine  branches.  Openchowsky  has  demonstrated 
large  masses  of  ganglion  cells  not  only  at  the  pylorus,  but  all  along  the 


736  NEUROSES    OF    THE    STOMACH. 

fundus  and  cardia  in  the  serosa ;  these  ganglia  are  in  communication 
with  the  large  vagosympathetic  fibers. 

Our  knowledge  of  the  physiology'  of  the  gastric  nerves  is,  up  to  the 
present  time,  ver\'  limited.  Since  the  publication  of  the  first  edition, 
Pawlow  has  repeated  and  published  his  work  on  gastric  innervation 
and  secretion  ("Die  Arbeit  d.  A^erdauungsdriisen,"  S.  71),  which 
proves  beyond  a  doubt  that  the  vagus  is  the  secreton,-  ner\'e  of  the 
gastric  glands.  The  influence  of  the  A'agus  and  sympathetic  fibers  on 
peristalsis  is  but  imperfectly  understood.  Although  we  do  not  know 
the  exact  paths  of  vast  secretor}^  motor  and  absorptive  impulses,  nor 
of  sensation,  it  is  generall}'  assumed  on  clinical  grounds  that  each  of 
these  functions  is  represented  by  dift'erent  nerves,  and  we  therefore 
accept  the  existence  of  special  nerves  for  motion,  sensation,  secretion, 
and  absorption.  Clinical  experience  has  confirmed  this  assumption 
because  peristaltic,  sensorv',  and  secretive  disturbances  ma}'  exist  by 
themselves. 

All  gastric  neuroses  may  show  considerable  variation  in  their 
course.  Thus,  the  contents  of  the  stomach  may  one  day  show  an- 
acidity  or  achjy'lia,  and  on  the  next  day  show  hyperchylia.  In  the 
same  manner  we  may  find  motor  insufficiency  alternating  with  peris- 
taltic unrest.  Although  the  neuroses  may  exist  singly  as  individual 
diseases,  we  are  confronted,  as  a  rule,  with  combinations  of  various 
disturbances.  Thus,  we  may  find  that  hyperacidity  and  gastro- 
spasm  are  associated  with  each  other,  that  hyperesthesia  will  be  com- 
bined with  vomiting,  and  that  supersecretion  may  be  present  in  atony. 
These  diseases  may  develop  pronounced  attacks  at  periods  when  the 
stomach  is  resting.  The  intensity  of  the  attack  is  ver\^  frequently 
entirely  independent  of  the  quantity  or  quality  of  the  food,  but  the 
effect  of  psychic  influences  is  generally  unmistakable.  Neuroses 
may  exist  side  by  side  with  organic  diseases  of  the  stomach,  but,  as  a 
rule,  they  are  part  of  the  symptomatology  of  neurasthenia  or  hys- 
teria. The  symptoms  of  a  general  neurosis  are  rarely  absent :  that  is, 
the  characteristic  changes  of  the  psychic  indisposition,  the  lassitude, 
irritability,  feeble  memory,  indisposition  to  work,  insomnia,  neuralgia, 
migraine,  vertigo,  polyuria,  weakness  of  the  bladder,  and  a  varying 
pain.  All  these  neuroses  which  we  have  mentioned  are  really  not 
individual  diseases,  but  rather  symptoms;  but,  as  these  symptoms 
general^  occur  with  a  certain  independence  and  are  disturbances 
peculiar  to  themselves,  it  will  not  be  illogical  to  call  the  complex 
anomalies  by  the  name  of  one  symptom,  so  that  we  will  speak  of  car- 


CARDIOSPASM.  737 

diac  Spasm  and  nervous  eructation  and  hyperacidity  as  diseases 
peculiar  to  themselves,  bearing  in  mind,  however,  that  we  are  simply 
describing  symptoms. 

CARDIOSPASM  (Cramp  of  the  Cardia). 
The  etiology  of  spasm  of  the  ring  musculature  of  the  cardia  agrees 
fully  with  that  of  cramp  of  the  pylorus.  In  the  great  majority  of 
cases  the  cramp  of  the  cardia  represents  a  secondary  disease,  which 
may  appear  with  hyperesthesia  and  very  strong  irritation  of  the 
mucous  membrane  of  the  cardiac  region ;  further,  with  abnormal  di- 
lation of  the  stomach  through  air  and  gases,  as  well  as  with  caustic 
action  upon  the  mucous  membrane  present  with  ulcer  and  ulcerating 
carcinoma  of  the  cardia ;  hence,  it  is  produced  by  the  same  causes  as 
cramp  of  the  pylorus.  Much  more  rarely  the  spasm  of  the  cardia  is 
due  to  a  genuine  symptomatic  or  idiopathic  neurosis  of  the  motor 
apparatus,  which  is  characterized  by  an  increased  irritability.  It  is 
observed  as  a  symptom  of  hysteria  and  neurasthenia,  simultaneous 
with  other  nervous  disturbances,  which  may  facilitate  the  recognition 
of  the  neuropathic  basis  of  this  form  of  cramp.  Whether  cramp  of 
the  cardia  as  a  pure  neurosis  of  the  motor  apparatus  is  a  functional 
impairment  of  the  peripheral  motor-nerve  apparatus,  or  whether  it  is 
of  central  origin,  is  at  present  still  a  debated  question.  We  may 
distinguish  two  forms  of  cramp  of  the  cardia : 

1.  Acute  cramp,  which,  appearing  rather  suddenly,  often  spas- 
modically, is  generally  only  of  short  duration. 

2.  Chronic  cramp,  which  is  a  very  stubborn  and  serious  disease. 
One  of  the  most  frequent  causes  of  the  rare  form  of  secondary 

cramp  is  dilation  of  the  stomach  by  air  and  gases.  An  abnormal 
dilation  of  the  stomach  by  air,  which  may  finally  bring  about  a  cramp 
of  the  cardia,  is  found  mostly  in  those  persons  who  have  the  nervous 
habit  of  swallowing  large  quantities  of  air.  If  the  air  is  not  soon 
removed  through  eructation,  it  keeps  on  collecting  in  the  stomach 
and  expands  on  becoming  warmed,  so  that  finally  a  considerable 
dilation  of  the  stomach  is  produced,  and  with  it  cramp  of  the  cardia, 
which  is,  perhaps,  always  complicated  with  cramp  of  the  pylorus. 
Ewald  and  Fleischer  have  had  opportunity  to  examine,  repeatedly, 
cases  of  intentional  swallowing  of  air.  Fleischer's  case  was  a  girl  who 
had  been  practising  it  as  a  kind  of  sport  for  many  years.  The  stom- 
ach was  constantly  dilated,  even  in  a  jejune  state,  and  felt  like  an  air- 
pniow.     The  rounding  of  the  region  of  the  stomach  was  plainly  visi- 


738  NATURE   OF   CARDIOSPASM. 

ble,  even  through  the  clothing.  The  elastic  stomach-tube  introduced 
into  the  esophagus  met  an  obstruction  at  the  cardia,  which  was  not 
easily  overcome,  even  after  the  insertion  of  the  tube  into  the  stomach. 
When  the  outer  end  was  put  into  water,  numerous  bubbles  of  air 
escaped  through  it ;  but  even  with  a  strong  external  pressure  in  the 
region  of  the  stomach  one  could  not  succeed  in  removing  all  the  air. 
The  resistance  in  this  region  continued,  though  to  a  less  degree.  With 
repeated  thorough  palpation  it  was  discovered  that  the  cramp  of  the 
cardia  and  pylorus,  occurring  intermittently  for  many  years,  had 
caused  a  hypertrophy  of  the  musculature  of  the  stomach ;  and  it  was 
this  condition,  probably,  which  prevented  the  formation  of  a  more 
severe  atony  and  ectasia  of  the  stomach,  for  the  lower  limit  of  the 
stomach  was  only  slightly  below  the  normal. 

The  stomach  may  also  be  dilated  by  a  very  copious  intragastric 
formation  of  gases  to  such  a  degree  that  a  cramp  of  the  cardia  arises; 
and  this  happens  very  easily  when  the  formation  of  gases  is  very 
rapid,  as  is  observed  sometimes  w4th  protracted  stagnation  of  the 
ingesta  in  the  stomach,  as  a  result  of  atony,  ectasia,  chronic  gastritis, 
advanced  stenosis  of  the  pylorus  or  duodenum,  as  well  as  with  pri- 
mary and  secondary  cramp  of  the  pylorus,  when  the  contents  of  the 
stomach  are  subject  to  fermentation  and  decomposition.  If  the  gases 
can  not  pass  over  into  the  intestine,  the)^  continue  to  collect  in  the 
stomach,  which  finally  becomes  very  much  dilated;  the  region  of  the 
stomach  becomes  arched,  and  troublesome  sensations  of  pressure  and 
tension  appear  in  the  same.  If  the  stomach  presses  the  diaphragm 
upward,  and  if  the  latter  in  turn  presses  on  the  lower  part  of  the  lung 
and  the  heart,  dyspnea,  precordial  oppression,  palpitation  of  the 
heart,  and  "asthma  dyspepticum"  may  result.  With  this  there 
sometimes  exist  great  prostration,  rapid,  soft  pulse,  and  headache. 
That  these  very  often  dangerous  symptoms  are  really  caused  by  the 
dilation  of  the  stomach  and  not,  perhaps,  by  autointoxication, — that 
is,  by  toxic  products  of  fermentation  and  putrefaction  of  the  chyme, 
— is  evident  from  the  fact  that  the  symptoms  cease  quickly  when  the 
cardiac  closure  is  finally  broken  (the  pylorus,  on  account  of  its  very 
much  stronger  ring  musculature,  offers  a  much  greater  resistance  to 
the  passage  of  the  gases  into  the  intestines),  when  the  spasm  relaxes, 
or  a  tube  is  introduced  into  the  stomach,  and  the  air  or  gases  have  an 
opportunity  to  escape  outwardly.  Very  rapid  distention  of  the  stom- 
ach with  air  pumped  in  through  the  tube  or  evolved  from  bicarbonate 
of  sodium  by  tartaric  ac'd  may  bring  on  cardiospasm  of  a  short  and 


SYMPTOMS   AND   COMPLICATIONS    OF    CARDIOSPASM.  739 

transient  nature.     In  highly  neurotic  patients  distention  should  be 
carried  out  very  slowly. 

On  the  other  hand,  the  cramp  of  the  cardia  may  also  be  primary, 
and  the  dilation  of  the  stomach  (pneumatosis)  may  be  secondary. 
If  the  cramp  of  the  cardia  sets  in  immediately  after  the  meal,  and  if 
the  eructation  of  the  air  which  is  swallowed  during  the  meal  with 
the  food  and  liquids  is  prevented,  then  the  stomach  may  also  become 
abnormally  distended.  Since  the  neuromuscular  apparatus  of  the 
cardia  is  mechanically  irritated  with  strong  distention  of  the  stom- 
ach, the  cramp  is  prolonged  thereby,  and,  therefore,  it  probably  lasts 
longer  during  digestion  than  with  an  empty  stomach.  Just  as  the 
removal  of  air  and  gases  from  the  stomach  through  eructation  is 
sometimes  made  entirely  impossible  by  a  primary  or  secondary  cramp 
of  the  cardia,  so  the  removal  of  the  contents  of  the  stomach  by  vomit- 
ing may  also  be  made  impossible.  Even  the  strongest  efforts  at 
vomiting  bring  up  nothing,  and  patients  may  be  much  tormented  by 
fruitless  muscular  exertion.  When  this  is  of  long  duration  and  fre- 
quent repetition,  it  may  bring  about  atony  of  the  stomach  in  conse- 
quence of  overexertion  of  the  musculature.  If  the  cramp  is  caused 
as  a  secondary  or  reflex  neurosis  by  hyperesthesia,  strong  irritation,  or 
ulceration  of  the  mucous  membrane  of  the  cardia,  it  sometimes  pro- 
duces a  painful  feeling  of  contraction  in  the  region  of  the  cardia,  which 
may  radiate  toward  the  breast,  the  back,  and  to  the  region  of  the 
heart.  It  has  been  asserted  that  the  cramp  which  appears  as  a  pure 
neurosis  of  the  motor  apparatus  may  also  cause  the  same  sensations 
of  pain,  but  this  is  not  very  probable.  At  least  my  observations  with 
that  form  of  cramp  of  the  pylorus  that  is  not  dependent  upon  the 
states  of  disease  before  mentioned,  but  depends  simply  upon  a  pure 
neurosis  of  the  motor  apparatus,  argue  against  it,  since  the  latter  is 
not  accompanied  by  pain.  The  pains  described  are  not  a  constant 
symptom,  and,  therefore,  may  not  be  used  as  a  factor  in  a  differential 
diagnosis  of  the  two  forms  of  cramp.  Since  v/ith  an  entirely  empty 
stomach  the  acute  spasm  produces  no  symptoms,  it  may  remain 
latent  for  some  time,  and  is  sometimes  recognized  only  by  accident, 
when  for  some  reason  a  tube  is  introduced  into  the  stomach  which 
meets  an  obstruction  in  the  region  of  the  cardia,  or  when  food  or 
drink  is  taken  by  the  patient  during  the  cramp,  deglutition  being 
then  irnpeded.  Chronic  cardiospasm  gives  much  more  significant 
symptoms.  Besides  the  symptoms  mentioned  previously,  very 
severe  complaints  from  deglutition  appear.  The  patients  have  the 
49 


740  SYMPTOMS  AND   PROGNOSIS   OF   CARDIOSPASM. 

unmistakable  feeling  that  some  of  the  food  becomes  stuck  before  it 
reaches  the  stomach.  If,  in  spite  of  this,  the  meal  is  continued,  the 
lower  part  of  the  esophagus  is  filled  with  food,  which  after  some  time 
the  patients,  with  great  exertion,  succeed  in  bringing  up  again  in  an 
almost  unchanged  condition.  That  it  comes  from  the  esophagus  and 
not  from  the  stomach  is  shown  by  the  absence  of  the  free  hydrochloric 
acid.  The  second  deglutition  sound  (auscultation  over  the  lower 
part  of  the  sternum)  is  always  lacking,  and  in  its  place  a  low,  rippling 
noise  may  be  heard,  which  probably  arises  from  the  circumstance 
that  the  cardia  is  not  completely  closed,  and  liquids  pressed  on  may 
still  flow  into  the  stomach.  With  protracted  duration  of  the  malady, 
the  ingesta  remaining  in  the  lower  part  of  the  esophagus  may  exert 
such  a  pressure  upon  its  walls  that  a  diverticulum  may  be  formed, 
which  prevents  the  taking  in  of  food.  The  nutrition  of  patients  may 
be  much  reduced,  so  that,  especially  when  the  patients  are  advanced 
in  age,  the  suspicion  may  arise  that  a  carcinoma  of  the  cardia  is  de- 
veloping, which,  as  we  know,  can  also  cause  a  stenosis  of  the  cardia 
as  well  as  the  formation  of  a  diverticulum. 

Fortunately,  chronic  cramp  of  the  cardia  is  a  very  rare  malady ;  it 
may  exist  for  months,  even  years. 

Prognosis. — The  prognosis  of  the  acute  primary  or  secondary 
cramp  of  the  cardia  is,  on  the  whole,  favorable,  especially  when  it  is 
recognized  in  time,  and  if  one  is  successful  in  rapidly  removing  its 
fundamental  causes — swallowing  of  air,  formation  of  gases  in  the 
stomach,  hyperacidity,  hypersecretion,  atony,  hyperesthesia,  etc. 
The  prognosis  is  always  to  be  made  with  caution  when  a  diverticulum 
of  the  esophagus  which  hinders  the  passage  of  food  has  already  been 
formed. 

Diagnosis.— In  order  to  distinguish  acute  primary  and  secondary 
cramp,  one  must  learn,  above  all,  whether  one  of  the  diseases  before 
mentioned,  which  can  produce  cramp  of  the  cardia,  is  present.  With 
repeated  thorough  investigations  one  generally  succeeds  in  determin- 
ing the  cause  of  the  secondary  cramp.  If  it  is  due  to  hyperesthesia, 
to  a  strong  irritation,  or  to  loss  of  substance  of  the  mucous  membrane 
of  the  cardia,  then  pains  in  the  region  of  the  cardia  often  draw  atten- 
tion to  this  manner  of  origin,  and  the  introduction  of  a  tube  into  the 
stomach  will  then  cause  pain  also.  But  if  a  decided  cause  for  the 
cramp  can  not  be  discovered,  if  it  recurs  periodically,  if  it  is  always 
of  rather  short  duration,  and  if  other  nervous  troubles  are  present, 
then  probably  a  symptomatic  functional  neurosis  exists;  and  if  all 


DIAGNOSIS    OF    CARDIOSPASM.  741 

these  signs  are  lacking,  then  there  is  an  idiopathic  functional  motor 
neurosis ;  but  this  is  a  very  rare  occurrence. 

The  diagnosis  of  the  chronic  cardiospasm  leading  to  a  permanent 
closure  of  the  cardia  is  more  difficult,  as  it  may  easily  be  mistaken  for 
carcinoma  or  malignant  stenosis  of  the  cardia,  as  well  as  for  a  diver- 
ticulum of  the  lowest  part  of  the  esophagus,  which,  however,  is  rare. 

Advanced  age,  anemia,  and  cachexia,  appearing  at  a  time  in  which 
the  passage  of  food  is  not  yet  hindered  to  a  great  extent,  argue  for 
carcinoma  of  the  cardia.  In  the  food  brought  up  by  regurgitation, 
as  well  as  in  the  examination  with  the  tube,  one  often  finds  traces  of 
blood,  and  in  some  few  cases  particles  of  carcinomatous  structure 
(in  the  aperture  of  the  tube).  In  most  of  the  patients  free  hydro- 
chloric acid  is  wanting  in  the  contents  or  food  that  may  be  drawn  from 
the  esophageal  diverticulum.  The  more  the  stenosis  increases  with 
the  progress  of  the  carcinoma,  the  thinner  the  tubes  that  must  be 
used  in  order  to  pass.  Cicatricial  stenosis  of  the  cardia  is  less  fre- 
quent, a  diverticulum  of  the  lowest  section  of  the  esophagus  much 
rarer,  than  carcinoma  of  the  cardia.  Both  diseases  are  not  connected 
with  any  particular  age.  The  nutrition  of  the  patients  is  decreased 
only  when  the  passage  of  the  food  is  very  much  impeded.  In  the 
formation  of  diverticulum  traces  of  blood  in  the  contents  of  the  tube 
are  generally  lacking,  and  with  cicatricial  stenosis  they  are  very  rare. 
With  diverticulum,  tubes  of  different  thicknesses  sometimes  pene- 
trate into  the  stomach  at  the  first  attempt,  at  other  times  only  after 
many  fruitless  endeavors,  according  as  the  stomach  is  full  or  empty. 
With,  stenosis,  when  there  is  much  difficulty  in  deglutition,  only  thin 
tubes  can  penetrate.  In  both  maladies  there  are  no  anomalies  of 
secretion  in  the  stomach.  With  carcinoma,  as  well  as  with  stenosis 
of  the  cardia  and  with  diverticulum,  the  difficulties  of  deglutition  in- 
crease very  gradually,  while  in  the  case  of  cramp  they  generally  come 
to  an  acute  stage  in  a  short  time.  The  chronic  cramp,  which  is  very 
rare,  may  appear  at  any  age.  The  general  nutrition  suffers  only  after 
protracted  duration.  Traces  of  blood  can  neither  be  found  in  the 
examination  with  the  tube  nor  in  the  food  that  is  eructated. 

The  examination  of  the  contents  of  the  stomach  in  cases  of  simple 
cramp  of  the  cardia  shows  nothing  abnormal.  With  intermittent 
relaxation  of  the  cramp,  the  difficulties  of  deglutition  cease  tempo- 
rarily, and  a  rigid  tube  may  be  pushed  into  the  stomach  without  meet- 
ing with  any  resistance;  neither  of  these  phenomena  are  observed 
with  carcinoma  and  stenosis,  except  in  the  rare  case  of  disintegration 


742  CARDIOSPASM. 

of  the  carcinoma.  An  important  distinction  of  the  cramp  con- 
sists in  the  fact  that  thick,  rigid  tubes  overcome  the  obstacle  at  the 
entrance  of  the  stomach  much  more  easily  than  thin  tubes.  The 
same  observations  have  been  made  repeatedly  with  spastic  stricture 
of  the  urethra,  which  is  generally  a  result  of  hyperesthesia  of  the 
mucous  membrane  of  the  urethra.  If  in  this  case  a  thin  catheter  is 
introduced,  its  point,  with  moderate  pressure,  irritates  only  one  spot 
of  the  mucous  membrane,  and  by  this  a  cramp  of  the  musculature  is 
produced  (or  a  previously  existing  one  is  increased),  which  becomes 
so  severe  that  it  may  easily  be  mistaken  for  an  organic  stricture.  A 
wrong  diagnosis  is,  however,  easily  avoided  if  the  mucous  membrane 
is  first  anesthetized  with  a  four  per  cent,  solution  of  cocain.  Then, 
after  a  short  time,  one  can  push  the  catheter  further.  If  a  much 
thicker  catheter  is  introduced,  the  broader  point  of  the  same  wHl 
exert  an  even  pressure  upon  the  whole  mucous  membrane  at  the 
point  in  question,  which  is  not  so  irritating.  Probabty  the  sensory 
nerves  are  then  for  a  time  paralyzed,  and  the  cramp  abates.  Very 
likely  the  same  conditions  obtain  in  the  probing  of  the  esophagus. 
If  after  protracted  duration  of  a  cramp,  a  diverticulum  of  the  esopha- 
gus has  been  formed,  considerable  quantities  of  food  may  be  retched 
up  at  one  time,  and  a  thick  tube  will  then  pass  the  obstacle  at  the  en- 
trance of  the  stomach,  the  facility  of  the  passage  depending  on  the 
fullness  of  the  diverticulum,  and  sometimes  the  passage  is  accom- 
plished only  after  many  unsuccessful  endeavors. 

In  all  cases  when  there  is  an}^  doubt  about  the  differential  diagnosis 
between  cardiospasm  and  carcinoma  of  the  cardia,  the  patient  should 
be  examined  under  anesthesia.  If  the  passage  becomes  readily 
permeable  to  the  sound  under  narcosis,  carcinoma  can  be  excluded. 

Among  the  severest  cases  of  this  type  occurring  in  my  experience 
was  that  of  a  girl  ten  years  old.  The  diagnosis  was  difficult — it  could 
not  be  decided  whether  it  was  a  diverticulum,  a  cicatricial  stenosis, 
or  cardiospasm.  For  two  weeks  the  tube  inevitably  became  caught 
above  the  cardia.  Eventually,  I  succeeded  in  passing  a  tube  under 
anesthesia,  and  thereafter  the  intubation  became  less  difficult  of 
execution  even  while  the  patient  was  conscious.  For  a  month  pre- 
vious to  consulting  me  the  child  could  not  swallow  any  solid  food, 
which  had  resulted  in  extreme  emaciation.  After  three  intubations 
under  anesthesia  she  began  to  swallow  semisolid  food  material,  and 
she  was  ultimately  cured  by  electricity  and  daily  passage  of  the  tube. 


TREATMENT  OF   CARDIOSPASM.  743 

Naturally,  the  inspection  of  the  esophagus  with  the  esophago- 
scope  would  decide  most  of  such  cases.      (See  p.  i86.) 

Therapeutics. — The  patient  must  abstain  from  all  injurious  influ- 
ences. The  abnormal  conditions  which,  according  to  experience, 
produce  cramp  of  the  cardia,  must  be  removed.  Those  who  swallow 
air  must  be  cautioned  against  the  bad  effects  of  the  habit.  With 
strong  dilation  of  the  stomach  through  air  and  gases,  in  consequence 
of  fermentation  and  stagnation  of  the  contents,  the  air  and  gases 
should  be  removed  as  quickly  as  possible  by  the  introduction  of  a 
rather  thick,  rigid  tube,  and  a  more  copious  formation  of  gases  must 
be  prevented  by  methodical  lavage  of  the  stomach,  often  with  the 
addition  of  antiseptics.  The  diet  must,  for  some  time,  consist  of  milk, 
and  later  of  various  meats  taken  in  a  minced  form.  Other  nervous 
disorders  must  receive  suitable  treatment.  One  of  the  best  methods 
of  treatment  for  cramp  of  the  cardia  is  the  introduction  of  firm,  thick 
tubes,  which  are  permitted  to  remain  in  position  for  thirty  minutes 
at  a  time.  Sometimes  the  cramp  ceases  entirely  after  sounding  one  or 
more  times.  If  the  spasm  is  the  consequence  of  the  hyperesthesia  of 
the  mucous  membrane  of  the  esophagus  and  cardia,  the  sensibility  is 
blunted  by  frequent  soundings. 

In  very  stubborn  cases  of  hyperesthesia  with  cardiospasm  it  is  ad- 
visable to  apply  a  solution  of  cocain  hydrochlorate  to  the  mucous 
membrane  just  before  the  meal,  in  order  to  prevent  the  appearance  of 
the  cramp.  For  this  purpose  one  had  best  use  a  small  sponge,  satu- 
rated with  a  three  per  cent,  solution  of  cocain,  and  fastened  to  the 
lower  end  of  an  open,  rather  thick,  firm  tube,  with  rounded  edges,  by 
means  of  a  strong  silk  thread  brought  through  the  tube  to  its  upper 
end.  After  introducing  the  tube  into  the  cardia,  the  cocain  solution  is 
forced  out  of  the  sponge  by  pulling  the  silk  thread,  or  by  blowing  air 
into  the  tube,  and  the  mucous  membrane  may  thus  be  anesthetized. 
Another  way  of  accomplishing  this  is  with  the  Einhorn  intragastric 
spray,  by  which  the  lower  part  of  the  esophagus  and  the  cardia  may 
be  sprayed  with  cocain  and  menthol.  With  chronic  cardiospasm 
also  the  methodical  introduction  of  firm  tubes  is  the  most  successful 
remedy.  The  effect  may  be  aided  by  external  or  internal  galvaniza- 
tion (the  anode  in  the  tube).  According  to  an  interesting  observa- 
tion of  Boas,  solid  foods  are  sometimes  introduced  more  easily  than 
liquid  ones.  Before  meals  the  foods  lying  in  front  of  the  cardia  are 
to  be  removed  as  completely  as  possible,  especially  when  a  diverticu- 
lum should  have  developed  (rare). 


744  PYLORIC    SPASM. 

In  both  acute  and  chronic  cardiospasm  we  have  obtained  the  most 
permanent  reHef  by  the  galvanic  current.  The  length  of  the  esopha- 
gus is  determined  b}"  methods  devised  by  Penzoldt  (/.  c.)  and  Isert 
Perl,  and  a  rather  large  spiral  electrode  (Stockton's)  is  introduced  to 
a  distance  compelling  it  to  be  in  or  near  the  cardia;  the  cathode  is 
placed  on  the  cerA^cal  region,  the  anode  in  the  cardia,  and  a  current 
of  twenty-five  milliamperes  is  turned  on  for  ten  minutes.  Then  the 
same  procedure  is  repeated  with  the  anode  on  the  epigastrium  and 
cathode  in  the  cardia. 

PYLORIC  SPASM  (Pylorospasm,  Cramp,  Convulsion,  Spasm  of  the 

Pylorus). 

Cramp  of  the  ring  musculature  of  the  pylorus  is  brought  on  by 
entirely  different  causes:  it  may  appear  with  hyperesthesia,  with 
very  strong  chemical  irritation  of  the  mucous  membrane  of  the  pylo- 
rus by  means  of  hydrochloric  acid  (h5^peracidity,  supersecretion),  by 
excess  of  organic  acids,  as  well  as  with  dilation  of  the  stomach  by 
gases  (as  a  reflex  neurosis),  and  finally  also  after  the  caustic  action  of 
toxic  substances,  and  further  as  a  secondary  disease  accompanying 
ulcer  and  ulcerating  carcinoma  of  the  pylorus.  ^A^hHe  the  existence 
of  a  secondary  cramp  of  the  pylorus  is  generally  recognized,  strange 
to  say  the  existence  of  a  primary  cramp  of  the  pylorus,  caused  by  an 
independent  motor  neurosis,  restricted  to  the  pylorus  alone,  is  still 
generally  denied.  If  one  grants,  however,  that  the  insufficiency  of 
the  pjdorus  may  appear  also  as  a  genuine  motor  neurosis,  due  to  a 
decrease  of  the  irritability  of  the  motor  ner^^e  apparatus  of  the  pylo- 
rus, there  is  no  reason  to  deny  entirely  the  occurrence  of  a  primary 
cramp  of  the  pylorus,  which  is  due  to  an  abnormally  increased  irri- 
tability of  the  motor  nerves,  even  though  this  be  rare.  Indeed, 
Stiller,  one  of  the  most  competent  judges  of  neuroses  of  the  stomach, 
assumes  a  primary  cramp  of  the  pylorus  for  the  explanation  of  peri- 
staltic unrest  of  the  stomach.  It  is  true  its  detection,  as  weU  as  that 
of  the  secondar}'-  spasm,  is  very  difficult,  since  the  most  important 
result  of  the  same — namely,  an  increased  peristalsis  of  the  stomach 
— can  not  be  proved  with  normal  location  and  size  of  the  stomach 
except  by  Hemmeter's  or  Einhorn's  method.* 

*  In  a  singular  case  of  periodic  pylorospasm  occurring  in  a  hysterical  female  regularly 
at  the  menstrual  period,  we  obtained  a  record  with  our  triple  intragastric  bag  which  may 
be  characteristic  of  these  cases.  This  bag  ("  N.  Y.  Med.  Jour.,"  June  22,  1896)  records 
the  pyloric,  fundic,  and  cardiac  peristalsis  separately  on  three  tambours  on  the  kymograph 


RESULTS    OF    PYLOROSPASM.  745 

The  existence  of  a  primary  cramp  of  the  pylorus  becomes  probable 
if,  after  the  exclusion  of  the  before-mentioned  causes  (secondary 
cramp  of  the  pylorus),  as  well  as  of  organic  disease  of  the  stomach, 
the  reaction  for  iodin  in  the  saliva  occurs  much  later  than  under 
ordinary  circumstances,  after  the  introduction  of  o.i  iodoform  into 
the  stomach  with  the  test-breakfast.  According  to  A.  Lockhart 
Gillespie  (Brit.  Med.  Assoc,  July,  1898),  salol  was  absorbed  from  the 
stomach  in  a  dog  in  whom  he  produced  a  fistula  in  the  duodenum 
near  the  pylorus.  He  still  found  the  salicyluric  reaction  in  the  urine, 
although  no  salol  reached  the  small  intestine.  Stein  ("Wien.  Med. 
Wochenschr.,"  43,  1892)  found  that  salol  was  absorbed  from  the 
stomach,  and,  although  not  decomposed  in  that  organ,  it  may  appear 
as  salicyluric  acid  in  the  urine.  For  these  reasons  the  salol  test  can 
not  be  relied  upon  as  informing  us  concerning  the  presence  or  absence 
of  pyloric  stenosis.  The  diagnosis  becomes  probable  also  when  atony 
of  the  stomach  appears  without  any  assignable  cause.  The  results  of 
a  primary  cramp  of  the  pylorus  are  the  same,  naturally,  as  those  of 
the  secondary.  Since  contents  of  the  stomach  can  not  pass  into  the 
intestine  during  the  entire  duration  of  the  spasm,  there  must  result  a 
stagnation  of  the  ingesta  and  a  protracted  burdening  of  the  stomach, 
causing  atony  of  musculature,  which  also  becomes  gradually  ex- 
hausted through  the  energetic  exertions  for  overcoming  the  increased 
resistance  at  the  pyloric  orifice.  If  the  neurosis  is  very  stubborn,  the 
atony  may  pass  over  into  a  pronounced  dilation,  particularly  if  the 
stagnating  ingesta  decompose  rapidly  and  the  atonic  stomach  is  ab- 
normally distended  with  gases. 

Therapeutics. — If  a  primary  cramp  of  the  pylorus  is  suspected,  a 
digestible,  non-irritating  diet  is  to  be  prescribed  (see  chapter  on  Diet)  ; 
every  immoderate  burdening  and  dilation  of  the  stomach  through 
very  abundant  meals,  which  might  heighten  the  irritability  of  the 
motor  nerves,  is  to  be  avoided.  With  this  the  bromids,  preferably 
the  bromid  of  strontium,  in  liberal  doses  (3.0  (45  grs.)  to  5.0  (75  grs.) 
per  diem),  extractum  belladonnae  (0.02  (^  of  a  gr.)  to  0.03  (^  of  a  gr.)), 
and  codein  phosphate  (0.02  (^  of  a  gr.)  to  0.03  (|  of  a  gr.)),  chloral  hy- 
drate (10  grs.  t.  i.  d.)  are  to  be  prescribed.  Electricity  is  a  valuable 
adjuvant  to  the  treatment,  and  should  be  used  in  the  same  manner  as 

(see  p. '84),  and  in  this  case  the  pyloric  pen  showed  great  spastic  contractions,  and  tenes- 
mus lasting  from  three  to  tive  minutes  before  they  relaxed.  The  pens  recording  the 
fundic  and  cardiac  contractions  were  quiet  during  this  period  except  for  slight  passive 
movements  due  to  respiration  and  impulse  of  aorta. 


746  PERISTALTIC   UNREST. 

indicated  for  cardiospasm.  Spraying  the  pylorus  with  cocain  and 
menthol  is  a  satisfactory  treatment.  Under  narcosis  the  pylorospasm 
relaxes.  The  pylorus  may  be  intubated  by  the  author's  method : 
A  large  tube  once  passed  through  the  pylorus  will,  if  allowed  to  rest 
there  for  ten  minutes,  in  some  cases  act  in  a  very  gratifying  manner, 
allaying  the  spasm  without  any  other  treatment.  This  method  con- 
stitutes a  means  of  recognizing  pylorospasm. 

GASTROSPASM  (Convulsions  of  the  Stomach). 
Gastrospasm  is  a  neurosis  in  which  the  musculature  of  the  stomach 
is  so  strongly  contracted  that  the  whole  organ  may  become  hardened 
like  a  board,  and  may  be  recognized  by  palpation  as  a  resistant  mass 
through  the  lax  abdominal  integuments.  It  is  a  very  rare  disease. 
Whether  it  ever  occurs  as  an  independent  genuine  neurosis  of  the 
motor  apparatus,  or  whether,  as  is  generally  supposed,  it  occurs  only 
as  a  secondary  nervous  affection,  with  hyperesthesia  of  the  sensory 
nerves  of  the  stomach,  or  as  a  consequence  of  a  cramp  of  the  pylorus, 
combined  with  hypertrophy  of  the  musculature  of  the  stomach,  is 
still  an  open  question.  In  the  very  rare  cases  observed  thus  far  the 
single  paroxysms  of  gastrospasm  invariably  lasted  but  a  short  time, 
and  the  quick  intermission  might  be  sufficiently  explained  by  the 
enormous  overexertion  of  the  musculature  during  the  attack.  The 
treatment  is  the  same  as  for  hyperperistalsis  (Kussmaul). 

GASTRIC  HYPERPERISTALSIS  (Peristaltic  Unrest  (Kussmaul)— 
Tormina  Ventriculi  Nervosa). 

General  Considerations. — Peristaltic  unrest  is  the  name  given 
by  Kussmaul  to  a  state  of  the  stomach  first  described  by  him,  which 
is  characterized  by  the  appearance  of  extraordinarily  rapid  contrac- 
tions of  the  stomach,  following  close  upon  one  another,  which  appear 
especially  after  meals,  continuing  also  during  the  day  and  sometimes 
through  the  night  with  an  entirely  empty  stomach.  This  excess  of 
peristalsis  brings  about  very  disagreeable  sensations  of  heaving  to  and 
fro,  of  unrest,  and  contractions  in  the  region  of  the  stomach  which, 
without  being  really  painful, — as,  for  example,  the  so-called  cramps 
of  the  stomach  with  cardialgia, — may  nevertheless  annoy  the  patient 
very  much.  When  there  is  an  ectasia  or  a  dislocation  of  the  stomach 
present  simultaneously,  as  was  the  case  in  all  the  observations  up  to 
date,  these  abnormally  strong  contractions  of  the  stomach  can  be 
seen  and  felt  externally  through  the  lax  abdominal  integument  as 


ETIOLOGY  OF  hypErperistalsis.  747 

distinct  undulatory  motions.  The  peristaltic  waves  generally  run 
from  the  fundus  to  the  pylorus :  that  is,  from  left  to  right.  Besides 
the  peristaltic  motions,  in  a  small  proportion  of  cases  antiperistaltic 
motions  were  observed  also ;  sometimes  the  latter  were  observed  to 
exist  alone,  but  this  is  rare  (Schiitz,  Cohn,  Glax).  If  the  size  and 
location  of  the  stomach  are  normal,  the  objective  symptoms  are  lack- 
ing entirely,  and  only  the  subjective  complaints,  particularly  the 
feeling  of  unrest,  are  evident.  Sometimes,  also,  peristaltic  unrest  of 
the  small  intestine  coexists  with  that  of  the  stomach. 

Increased  irritability  of  the  motor  nerves  of  the  stomach  is  looked 
upon  as  the  cause  of  peristaltic  unrest. 

Etiology. — An  abnormally  increased  activity  of  the  stomach  may 
be  brought  about  by  different  causes : 

1.  As  a  reflex  process,  through  hyperesthesia  of  the  sensory  nerves 
of  the  stomach. 

2.  By  a  very  strong  stimulation  of  the  mucous  membrane  of  the 
stomach  by  HCl  (hyperacidity,  supersecretion),  by  organic  acids,  the 
result  of  an  abnormal  fermentation  of  the  contents  of  the  stomach, 
by  gases  which  distend  the  stomach  to  a  considerable  degree. 

3.  With  an  advanced  stenosis  of  the  pylorus  and  of  the  duodenum, 
and,  finally,  it  may  be  due  to  an  increased  irritability  of  the  motor 
nerves,  and  may  thus  be  the  result  of  an  independent  functional 
neurosis. 

The  question  arises.  Which  of  the  motor  nerves  of  the  stomach  take 
part  in  the  merely  functional  illness  in  the  case  of  peristaltic  unrest? 

While  Stiller,  who  has  paid  much  attention  to  neuroses  of  the 
stomach,  traces  back  peristaltic  unrest  to  a  cramp  of  the  ring  mus- 
culature of  the  pylorus,  other  authors  explain  it  by  an  increased  irri- 
tability of  those  motor  nerves  which  innervate  the  musculature  of 
that  region  of  the  stomach  lying  between  the  cardia  and  the  pylorus. 

In  severe  cases  the  anomaly  of  function  is  probably  extended  over 
all  the  motor  nerves  of  the  stomach,  since  with  cramp  of  the  pylorus 
alone  the  peristaltic  motions  are  not  so  intense  as  with  peristaltic 
unrest.  Fleischer  had  opportunity  of  convincing  himself  of  this  in  a 
case  of  dilation  of  the  stomach  in  which  the  greatly  contracted  pjdo- 
rus  could  each  time  be  felt  distinctly  through  the  lax  abdominal 
integuments. 

With'  normal  size  and  location  of  the  stomach  the  peristaltic  mo- 
tions are  not  visible  in  the  epigastrium,  in  spite  of  the  presence  of 
peristaltic  unrest,   on  account  of  the  thickness  of  the  abdominal 


748  HYPERPERISTALSIS. 

integument  and  because  a  part  of  the  stomach  is  under  the  liver ;  it  is 
thus  very  probable  that  many  cases  escape  detection.  Sexual  ex- 
cesses, repeated  intense  emotions,  an  unsuitable  mode  of  living, 
general  nervousness,  as  well  as  anemia,  increase  the  disposition  to 
this  disease. 

Symptomatology. — If  a  stomach  which  is  dilated  or  dislocated 
downward  is  seized  with  peristaltic  unrest,  the  symptoms  are,  in  de- 
cided cases,  so  characteristic  that  they  can  not  easily  be  overlooked 
or  mistaken.  The  very  strong  contractions  of  the  gastric  muscula- 
ture, repeating  quickly,  can  be  distinctly  seen  and  felt  as  undulatory 
motions,  especially  when  abdominal  integument  is  relaxed.  If  the 
stomach,  at  the  same  time,  contains  liquids  and  gases,  the  peristaltic 
waves  are  often  accompanied  by  strong,  gurgling  noises  which  can  be 
heard  at  some  distance.  These  undulatory  motions,  caused  by  rest- 
less action  of  the  muscles,  generally  run  in  the  direction  from  fundus 
to  pylorus:  that  is,  from  the  left  above  to  the  right  below,  more 
rarely  also  in  the  reverse  direction  of  right  to  left.  In  some  cases 
only  antiperistaltic  waves  have  been  observed.  By  the  contraction 
of  the  muscles,  the  fundus  of  the  stomach  may  at  times  be  distended 
to  the  size  of  a  child's  head,  so  that  it  strongly  arches  up  the  abdomi- 
nal walls. 

After  a  time  the  elevation  sinks,  to  appear  in  another  region  of  the 
stomach.  At  the  height  of  the  contraction  of  the  muscles  there  may 
be  a  slight  circular  constriction  or  furrow  seen  in  the  middle  of  the 
stomach,  dividing  the  organ  into  two  nearly  equal  parts,  so  that  it 
temporaril}^  assumes  the  shape  of  an  hour-glass. 

Since  the  muscular  undulations  can  be  observed  only  with  a  dilated 
or  dislocated  stomach,  they  naturally  extend  beyond  its  normal  loca- 
tion ;  if  peristaltic  unrest  of  the  small  intestine  exists  simultaneously, 
the  undulations  extend  also  over  a  part  of  the  hypogastric  region, 
and  even  with  an  empty  stomach  a  rolling  and  rumbling  noise,  origi- 
nating in  the  intestines,  can  be  heard. 

Slight  degrees  of  peristaltic  unrest  occurring  when  the  stomach  is  in 
a  normal  position  are  recognizable  by  the  aid  of  the  X-rays  and 
fluoroscope.  The  patient's  stomach  must  contain  about  one  liter  of 
milk  mixed  with  one  teaspoonful  of  subnitrate  of  bismuth. 

While  energetic  contractions  of  the  stomach  hasten  the  execution  of 
its  normal  functions,  an  excessive  peristalsis  has  a  directl}^  injurious 
effect,  and  causes  manifold  disturbances  of  digestion.  Patients  fre- 
quently complain  of  a  lack  of  appetite,  belching,  nausea,  and  vomit- 


SYMPTOMATOLOGY.  749 

ing.  If  the  peristaltic  unrest  is  very  stubborn,  the  patients  may  suf- 
fer a  loss  in  nutrition,  so  that  the  suspicion  seems  justified  that  malig- 
nant neoplasm  is  developing.  If  the  peristaltic  unrest  continues  also 
through  the  night,  the  state  of  mind  is  generally  much  depressed, 
because  patients  are  constantly  reminded  of  their  stomach  and  their 
disease;  any  neurasthenia  which  ma}^  be  present  is  often  considera- 
bly increased.  If  the  small  intestine  is  also  the  seat  of  active  peris- 
taltic unrest,  intestinal  gases  and  liquid  contents  sometimes  regurgi- 
tate into  the  stomach.  The  eructations  are  then  very  foul-smelling, 
and  often  feculent  masses  are  vomited,  which  may,  exceptionall}^ 
even  contain  scybala. 

The  demonstration  of  scybala  in  vomited  matter  indicates  that  the 
peristalsis  of  the  colon,  which  generally  is  not  concerned  in  peristaltic 
uiurest,  is  considerably  increased.  In  spite  of  peristaltic  unrest  of  the 
small  intestine,  very  stubborn  constipation  and  meteorism  often  occur, 
because  the  colon  is,  as  a  rule,  pacific  during  these  enteric  contortions. 

With  normal  size  and  location  of  the  stomach  the  objective  signs 
of  peristaltic  unrest  are  wanting,  and  sometimes  the  disagreeable 
sensations  of  unrest  in  the  region  of  the  stomach  constitute  the  only 
subjective  symptom  of  the  disease. 

Prognosis. — If  the  peristaltic  unrest  is  the  result  of  a  genuine, 
independent,  or  symptomatic  neurosis,  the  prognosis  on  the  whole  is 
favorable.  When  injurious  substances  before  mentioned  are  kept 
away,  and  the  primary  diseases — neurasthenia,  anemia — can  be  re- 
moved, the  peristaltic  unrest,  as  a  rule,  soon  recedes  with  suitable 
mode  of  living,  diet,  and  with  methodical  use  of  electricity. 

Diagnosis. — In  order  to  diagnose  with  certainty  that  type  of 
peristaltic  unrest  which  is  an  independent,  genuine  motor  neurosis, 
it  is  necessary  first  to  exclude  those  other  diseases  which  also  cause 
an  increased  peristalsis  of  the  stomach.  The  so-called  cramps  of  the 
stomach  with  cardialgia  are  accompanied  with  more  or  less  severe 
boring,  gnawing,  or  cramp-like  pains,  and,  therefore,  are  generally 
easily  recognized.  Whether  the  increased  peristalsis  is  the  result  of 
a  very  strong  irritation  of  the  mucous  membrane  of  the  stomach  by 
hydrochloric  acid,  organic  acids,  or  by  gases  which  distend  the  organ 
to  excess,  may  generally  be  easily  determined  by  a  repeated  chemical 
analysis  of  the  stomach  contents ;  further,  the  gastralgia  sometimes 
ceases  eiitirely  when  the  stomach  has  been  emptied  by  the  tube  and  is 
thoroughly  cleansed  (which  is  not  the  case  with  peristaltic  unrest). 
The  increased  peristalsis  of  dilation  resulting  from  stenosis  of  the 


750  HYPERPERISTALSIS. 

pylorus  or  duodenum  is  also  arrested  by  lavage.  The  diagnosis  is 
very  difficult  with  normal  size  and  location  of  the  stomach.  In  these 
cases  the  author's  method  of  graphically  recording  the  motor  func- 
tions by  the  deglutable  stomach-shaped  bag  is,  perhaps,  the  only 
reliable  means  of  settling  the  differential  diagnosis  between  peristaltic 
unrest  of  the  stomach  and  that  of  the  intestines.  In  fact,  in  all  neu- 
roses of  motility  the  intragastric  stomach-shaped  bag  gives  most 
valuable  information  of  the  nature  and  intensity  of  the  peristalsis. 
(See  p.  84.) 

One  may  suspect  peristaltic  unrest  when  the  symptoms  recede 
rapidly  after  methodical  application  of  electricity,  and  when  other 
nervous  disturbances  occur  coincidently.  In  the  distinction  of  peris- 
taltic unrest  of  the  stomach  from  that  of  the  intestine  one  should 
ascertain  whether  the  rolling  and  rumbling  is  still  audible  with  an 
empty  stomach,  and  whether  the  peristaltic  motions  can  also  be  per- 
ceived outside  of  the  limits  of  the  stomach.  If,  with  an  empty  stom- 
ach, every  splashing  noise  is  constantly  absent,  and  if  the  sounds 
appear  again  shortly  after  drinking  water,  this  argues  for  peristaltic 
unrest  of  the  stomach.  If  dilation  or  dislocation  of  the  stomach  can 
be  excluded,  the  visible  peristaltic  motions  are  to  be  ascribed  to  the 
intestines. 

Leube  has  described  cases  in  which  loops  of  small  intestine  were 
evidently  pushed  up  between  the  stomach  and  the  abdominal  waU 
while  in  active  peristalsis. 

Sedatives,  like  the  bromids,  opium,  and  belladonna,  are  said  to 
exert  a  more  controlling  effect  on  the  intestinal  than  on  gastric  hyper- 
peristalsis. 

Therapeutics. — The  sufferer  must  be  urged  to  keep  away  from 
injurious  influences,  such  as  sexual  excesses,  mental  shocks,  and  over- 
exertions, etc.,  and  lead  a  quiet,  regular  mode  of  life.  If  the  peris- 
taltic unrest  is  a  partial  or  resultant  effect  of  a  decided  neurasthenia 
or  anemia,  a  protracted  sojourn  in  the  country,  in  the  mountains,  at 
the  seashore,  and  hydropathic  procedures  (cold  rubbings,  baths)  will 
influence  favorably  the  nervous  system  and  the  composition  of  the 
blood ;  the  anemia  must  also  be  fought  by  a  strengthening,  easily  di- 
gestible diet  (scraped  meats),  and  by  iron  and  arsenic  preparations. 

In  severe  cases  in  which  the  peristaltic  unrest  continues  through  the 
night,  resting  in  bed  and  a  mild  diet  (milk,  soups)  are  recommended, 
and  cold  bandages  or  packings  of  the  stomach  should  be  tried,  and  if 
these  do  not  relieve,  then  warm  cataplasms.     Every  immoderate 


TREATMENT  OF   HYPERPERISTALSIS.  751 

loading  of  the  gastric  walls,  as  well  as  even,'  severe  dilation  of 
the  stomach  by  means  of  gases,  is  to  be  strictly  avoided,  in  order 
not  to  increase  the  irritability  of  the  motor  nerves.  Kussmaul 
obtained  very  favorable  results  b}^  the  internal  and  external  ap- 
plications of  electricity.  In  the  former  case  the  anode,  by  means 
of  the  tube,  is  inserted  into  the  stomach,  partially  filled  with  a  small 
quantity  of  a  normal  salt  solution  (0.6  per  cent.),  and  then  slow  rub- 
bing motions  are  to  be  made  with  the  cathode  externally  in  the  region 
of  the  stomach;  in  external  galvanization  the  anode  is  used  for  the 
last-mentioned  movements,  while  the  cathode  is  placed  on  the  ster- 
num. I  have  had  satisfactory  results  with  exclusive  rectal  feeding 
in  two  cases  of  peristaltic  unrest  in  which  the  stomach  was  in  the  nor- 
mal position.  The  rectal  nutritive  enemata  were  continued  for  six- 
teen days ;  thereafter  the  symptoms  disappeared. 

Of  the  medicines,  sodium,  ammonium,  or  strontium  bromid, — 
in  doses  of  three  to  five  gm.  (45  to  75  grs.)  in  twelve  hours, — extract 
of  belladonna,  dose,  0.008  to  0.013  gm.  (^  of  a  gr.  to  -l-  of  a  gr.),  or 
codein  phosphate,  dose,  0.02  to  0.03  gm.  (^  of  a  gr.  to  ^  of  a  gr.),  are 
to  be  recommended.  The  bromid  of  strontium,  20  grs.  four  times 
daily,  has  my  preference.  Exclusive  feeding  by  the  rectum  for  one 
week  is  more  effective  when  combined  with  rest  in  bed  and  the  use  of 
the  bromids.  In  a  persistent  case  of  peristaltic  unrest  in  a  gouty 
patient  I  obtained  very  good  results  from  salicylate  of  sodium  i 
scruple,  with  bismuth  subnitrate  16  grs.,  three  times  daily. 


NERVOUS   ERUCTATION. 

This  is  a  frequent  symptom  in  hysteria,  neurasthenia,  and  allied 
neuropathic  conditions.  It  is  said  to  be  particularly  frequent  in  the 
sexual  neuroses.  The  belching  up  of  tasteless  or  offensive  gases  is  a 
frequent  symptom  n  most  gastric  diseases.  In  fact,  it  occurs  at 
times  in  every  normal  person,  and  then  consists  of  the  sporadic  ex- 
pulsion of  air  that  has  been  swallowed  with  the  food,  or  of  CO2  that 
has  been  taken  in  with  beverages,  or  has  been  formed  by  fermenta- 
tion of  the  food.  The  pathological  condition  which  occurs  in  neu- 
rasthenia consists  of  the  explosive  evacuation  of  tasteless  gas  in  large 
quantities.  The  attacks  are  usually  paroxysmal,  and  the  gas  that  is 
expelled  is  generally  air,  which  is  not  formed  in  the  stomach,  but 
which  has  been  swallowed.  Every  time  air  is  eructated  from  the 
stomach  the  closure  of  the  cardia  must  be  opened,  and  with  a  frequent 


752  NEUROSES    OF    THE    STOMACH. 

repetition  of  this  a  permanent  relaxation  of  the  cardia  may  develop. 
The  muscular  development  of  the  pylorus  being  much  stronger,  this 
orifice  is  not  so  easily  opened  by  gas.  We  have  known  nervous  indi- 
viduals, particularly  hysterical  patients,  to  belch  up  air  during  the 
entire  day,  and  often  during  the  night.  Air  can  be  aspirated  into  the 
stomach  when  the  cardia  is  relaxed  and  the  esophagus  is  closed,  either 
in  consequence  of  a  negative  thoracic  pressure  when  the  vocal  cords 
are  closed,  or  because  the  lumen  of  the  stomach  expands  and  dilates 
under  nervous  influence.  On  the  other  hand,  some  nervous  patients 
have  the  bad  habit  of  intentionally  or  unconsciously  swallowing  air 
until  the  stomach  is  expanded,  when  the  same  air  is  eructated  with 
explosive  violence.  In  one  of  the  patients  of  Cartellieri  ("Wiener 
allgemeine  med.  Zeitung,"  1885,  S.  3),  2500  eructations  occurred  in 
one  hour.  Some  patients  have  dyspeptic  symptoms,  while  in  others 
digestion  is  not  disturbed.  I  have  personally  known  a  neurasthenic 
colleague  who  could  eructate  whenever  called  upon  to  do  so.  It  is 
probable  that  in  this  case  the  air  that  is  swallowed  does  not  reach  his 
stomach,  but  gets  no  further  than  the  upper  part  of  the  esophagus, 
when  it  is  again  expelled.  Oser  has  explained  the  aspiration  of  air 
into  the  stomach,  assuming  that  it  acts  on  the  principle  of  an  elastic 
balloon — the  contraction  of  the  longitudinal  muscle  enlarging  the 
gastric  lumen  and  thereby  sucking  in  air,  and  the  circular  muscle 
contracting  it  again  and  thereby  expelling  it.  This  would  not  explain 
all  cases,  because  in  some  hysterical  patients  the  eructation  is  so  rapid 
and  uninterrupted  that  there  seems  to  be  no  time  left  for  swallowing 
air  in  this  manner.  It  is  probable  that  a  clonic  spasm  of  the  pharyn- 
geal muscles  may  exist  here,  persistently  pressing  air  into  the  esopha- 
gus, which  eventually  reaches  the  stomach,  but  generally  is  expelled 
from  the  esophagus.  (Bouveret,  /.  c,  "Aerophagia.")  Esophageal 
eructation  and  vomiting  may  be  produced  by  hysterical  patients  at 
will.  Cartellieri  asserted  that  his  patient  (/.  c.)  had  no  time  to  swal- 
low air  during  the  attack,  and  Ewald  raises  the  question  whether 
these  attacks  are  really  nervous  eructations,  or  only  simulate  them. 

Pneumatosis. — This  is  a  condition  of  the  foregoing  disease,  in 
which  the  stomach  is  abnormally  expanded  with  air,  producing  a  sen- 
sation of  unpleasant  distention  and  dyspnea.  When  the  air  escapes 
into  the  mouth  or  intestines,  the  torturing  feelings  cease.  The  suffer- 
ing may  be  permanent  or  only  periodical,  and  has  been  attributed  to  a 
spasmodic  closure  of  the  cardia  and  pylorus.  The  dyspnea  that 
occurs  in  these  cases  has  much  similarity  to  the  "asthma  dyspepti- 


NERVOUS   ERUCTATION.  753 

cum"  of  Henoch.  Pneumatosis  may  be  easily  recognized  by  an 
inspection  and  percussion  of  the  inflated  stomach,  which,  of  course, 
should  be  differentiated  from  a  possible  distended  transverse  colon. 
In  many  cases  persistent  constipation  will  be  found  to  be  an  etiologi- 
cal factor,  for  in  these  cases  the  pneumatosis  rapidly  improves  when 
the  bowels  become  regular.  A  possible  gastric  dilation  and  atony 
must  be  excluded. 

Treatment. — The  patient  and  his  attendants  must  be  instructed 
that  the  eructation  and  the  pneumatosis  are  largely  a  habit,  and  that 
by  close  observation  of  the  patient  he  or  she  can  be  interrupted  in  the 
act  of  swallowing  air.  Penzoldt  cured  a  patient  of  this  kind  who  had 
been  uninterruptedly  swallowing  and  eructating  air,  by  making  him 
keep  his  mouth  open  for  a  half -hour,  as  it  is  impossible  to  swallow 
air  when  the  mouth  is  open.  The  eructation  ceased  entirely,  and  the 
patient  became  convinced  that  the  swallowing  of  air  was  the  cause  of 
his  suffering.  The  explosive  eructations  of  hysterical  patients  are 
best  treated  by  methods  directed  toward  the  psychical  condition  of 
the  case.  Quincke  has  seen  cures  by  introducing  a  thick,  soft  stom- 
ach-tube, and  permitting  it  to  rest  for  a  while  in  the  esophagus.  The 
cases  that  depend  upon  aspiration  by  alternate  expansion  and  con- 
traction of  the  stomach  are,  in  my  experience,  benefited  b)'-  the  intra- 
gastric application  of  the  galvanic  current.  The  neurasthenic  foun- 
dation of  the  disease  should  receive  careful  attention — thus  nervous 
eructation  and  pneumatosis  have,  in  my  experience,  been  repeatedly 
cured  by  a  course  of  surf -bathing,  as  well  as  the  Scotch  douche  ap- 
plied to  the  epigastrium.  Cold  sponging  and  massage  are  very  use- 
ful aids  in  treatment.  Among  the  drugs  that  have  been  recommended 
are  small  and  frequently  repeated  doses  of  arsenic,  belladonna,  or 
atropin,  hypodermic  injections  of  morphin,  and  cocain.  Boas  ob- 
tained good  results  from  the  following  pill : 

li  .     Extract,  physostigmatis, 0.13  gr-  'j 

Extract,  belladonnse  (Ale), 0.25  gr.  iv 

Strychnin  sulphate, 0.03  gr.  ss.  M. 

Fiant  pill,  No.  xx. 

SiG. — One  pill  three  times  a  day. 

Spraying  the  pharynx  with  solutions  of  cocain  and  menthol,  and 
the  internal  administration  of  bromid  strontium  are  available  thera- 
peutic measures.  Neurasthenia  depending  on  uric  acid  diathesis 
frequently  causes  nervous  eructations,  for  which  salicylate  of  sodium 
is  of  more  value  than  the  bromids. 


754  NEUROSES   OF   THE   STOMACH. 

NERVOUS,    HABITUAL,   OR   REFLEX   VOMITING. 

In  the  classical  experiments  of  Magendie  the  stomach  of  an  animal 
was  replaced  by  a  pig's  bladder,  and  after  tartar  emetic  was  injected 
into  the  blood,  the  contents  of  the  bladder  were  vomited;  this  ex- 
perimenter, accordingly,  concluded  that  the  stomach  had  nothing 
to  do  with  the  act  of  emesis,  but  that  it  was  brought  about  by  action 
of  the  abdominal  muscles.  Tintani,  however,  showed  later  on  that 
the  experiment  of  Magendie  no  longer  succeeds  when  the  cardia  still 
remains  intact  and  is  not  cut  away;  therefore  the  cardia,  inasmuch 
as  it  can  prevent  vomiting,  must  be  concerned  in  the  act  of  emesis, 
which  was  found  to  consist  of  firm  closure  of  the  pylorus,  opening  of 
the  cardia,  while  powerful  peristaltic  and  antiperistaltic  waves 
traveled  over  the  stomach.  The  main  force  for  emesis  is  then  fur- 
nished by  the  abdominal  muscles,  which  are  energetically  assisted 
by  the  contractions  of  the  stomach  itself.  There  are  three  forms  of 
nervous  vomiting:  (i)  The  cerebral  or  spinal  vomiting  (also  known 
as  central  vomiting),  which  is  caused  by  direct  or  indirect  stimula- 
tion of  the  vomiting  center  in  the  medulla  oblongata  from  other 
irritated  foci  in  the  brain  and  spinal  marrow.  (2)  Nervous  vomit- 
ing, occurring  as  a  symptom  of  hysteria  or  neurasthenia.  (3)  The 
reflex  vomiting,  in  a  more  restricted  sense,  brought  about  by  reflex 
irritations  from  various  other  organs  in  the  body. 

Cerebral  vomiting  is  a  frequent  symptom  in  organic  diseases  of 
the  brain  and  its  membranes,  particularly  when  they  are  associated 
with  circulatory  disturbances  or  changes  in  intracranial  pressure 
occurring  more  or  less  suddenly.  It  has  been  observed  in  acute  in- 
flammatory processes,  like  encephalitis  and  meningitis,  also  with 
cerebral  abscesses,  tumors,  and  focal  diseases.  It  may  result  from 
acute  anemia  or  hyperemia,  and  after  concussion  of  the  brain.  It  is 
said  to  occur  also  with  vivid  emotional  affections,  and  after  intoxica- 
tion by  opium,  chloroform,  ether,  nicotin,  and  also  in  uremia.  Spinal 
vomiting  in  diseases  of  the  cord  is  rarer,  but  it  is  quite  frequent  in 
exophthalmic  goiter  and  in  tabes  dorsalis,  in  which  it  occurs  in  form  of 
the  gastric  crises,  first  described  by  Charcot. 

Gastric  Crises. — In  a  majority  of  cases  the  gastric  crises  are  ac- 
companied not  only  with  severe  vomiting,  but  with  gastric  hyper- 
esthesia and  hyperchylia.  According  to  Leyden,  the  vomiting  may 
be  absent  entirely.  The  attack  begins  without  any  prodromal  symp- 
toms.    In  the  midst  of  well-being  the  patients  complain  of  intense, 


NERVOUS   VOMITING.  755 

spasm -like  pains  in  the  stomach,  particularly  in  the  epigastrium, 
which  radiate  to  the  sides  and  to  the  back.  The  face  is  pale,  the 
pulse  is  small,  soft,  and  rapid,  there  are  vertigo  and  palpitation  of  the 
heart.  The  bowels  are  constipated,  the  appetite  is  lost,  and  thirst  is 
great.  At  the  same  time  there  are  great  prostration  and  weakness 
and  a  clinical  picture  of  severe  collapse.  Although  the  patients 
drink  large  quantities  of  water,  they  pass  very  little  urine,  partly 
because  the  water  is  again  vomited,  or  because  it  can  not  enter  the 
intestines  on  account  of  an  existing  pyloric  spasm.  The  abdomen  is 
much  retracted  on  account  of  clonic  contractions  of  the  stomach  and 
intestines,  as  well  as  of  the  abdominal  wall.  Very  soon,  copious 
vomiting  begins.  First  food,  then  bile,  mucus,  and  particles  of  blood 
are  vomited.  The  reaction  of  the  vomit,  as  a  rule,  shows  hyperacid- 
ity. Von  Noorden  ("Charite  Annalen,"  1890,  S.  166)  and  Seymour 
Basch  have  reported  attacks  of  gastric  crises  in  which  the  acidity  for 
free  HCl  was  normal  or  subnormal.  The  degree  of  acidity  will  natur- 
ally vary  with  the  length  of  time  that  the  vomited  ingesta  have  re- 
mained in  the  stomach.  After  abundant  vomiting  transient  relief  is 
generally  experienced,  and  in  mild  attacks  this  may  be  the  end  of  the 
crisis ;  but  in  severe  attacks  the  vomiting  may  occur  hourly,  continu- 
ing to  the  evening,  with  very  short  intermissions.  During  the  night 
the  attacks  generally  cease,  to  return  again  on  the  following  day. 
This  course  of  symptoms  may  repeat  itself  in  eight  to  ten  days,  by 
which  time  the  debility  of  the  patient  is  very  great.  The  suffering 
may  cease  just  as  rapidly  and  suddenly  as  it  came.  The  vomiting 
stops,  the  appetite  improves,  and  the  general  condition  of  the  patient 
slowly  convalesces.  If  gastric  crisis  occurs  in  a  case  of  advanced 
tabes,  its  recognition  is  not  difficult,  but  when  it  occurs  as  one  of  the 
very  first  symptoms  of  tabes,  the  correct  diagnosis  may  be  difficult. 
In  that  case  we  must  test  the  patellar  reflexes,  the  reflexes  of  the 
pupil,  Romberg's  symptom  (increased  incoordination  of  movements 
by  placing  feet  together  and  closing  e3^es),  and  inquire  concerning  the 
existence  of  lancinating  pains.  In  case  the  connection  with  tabes 
is  not  established,  gastric  crises  may  be  mistaken  for  gastroxynsis, 
hemicrania,  or  hyperacidity.  Hemicrania — intense,  one-sided  head- 
ache— is  rarely  complained  of  in  gastric  crises.  The  gastric  pains  in 
hemicrania  are  insignificant.  Gastroxynsis  occurs  only  in  men,  after 
severe  mental  exertion  or  after  well-known  toxic  influences,  and  is 
always  incited  by  certain  opportune  and  traceable  causes,  which  is 
not  the  case  with  gastric  crisis. 
50 


756  NEUROSES   OF  THE   STOMACH. 

Periodical  Vomiting  (Leyden). — This  is  a  combination  of  symp- 
toms in  which  the  prominent  feature  is  vomiting  that  returns  in  regu- 
lar intervals.  In  some  cases  the  days  of  the  paroxysm  of  the  attack 
may  be  predicted  with  tolerable  accuracy.  The  attacks  begin  with- 
out any  marked  prodromal  symptoms,  in  the  midst  of  apparently 
good  health.  Gastralgia  may  introduce  the  attack  or  may  follow  it. 
The  appetite  is  lost,  pulse  small  and  frequent,  tongue  coated  and  dry. 
The  patients  may  have  intense  headache  and  even  slight  delirium. 
The  clinical  picture  is  very  similar  to  that  of  the  gastric  crisis.  The 
character  and  the  reaction  of  the  vomit  are  essentially  the  same.  The 
duration  of  the  attack  varies  between  twenty-four  hours  and  fourteen 
days ;  some  patients  have  lancinating  pains  in  the  extremities  in  place 
of  gastralgia.  Toward  the  end  of  the  attack  the  vomiting  gradually 
ceases,  and  the  remaining  complaints  slowly  disappear.  The  char- 
acteristic of  periodical  vomiting  is  that  the  attacks  occur  at  certain 
definite  intervals  of  from  two  to  ten  weeks.  The  repetition  occurs 
with  great  regularity,  and  the  disease  may  last  many  years. 

The  prognosis  is  therefore  a  very  doubtful  one.  The  distinction 
from  gastric  crisis  is  made  by  the  typical  periodicity,  and  the  pres- 
ence of  great  hyperacidity  of  the  vomit  in  the  crisis.  Periodical 
vomiting  appears  occasionally  as  a  primary,  idiopathic  neurosis  of  the 
vagi.  It  has  been  known  to  occur  with  hydronephrosis,  with  floating 
kidney,  diseases  of  the  uterus  and  ovaries,  with  intestinal  entozoa, 
and  nicotin  poisoning. 

Nervous  Vomiting  in  the  Course  of  Neurasthenia  and  Hys- 
teria.— This  vomiting  is  found  more  frequently  in  hysteria  than  in 
neurasthenia.  If  it  occurs  in  neurasthenia,  it  is  associated  with 
marked  sensitiveness  of  the  lower  thoracic  and  the  upper  lumbar 
vertebrai  to  the  electrical  current  (M.  Rosenthal).  The  patients  fre- 
quently complain  of  severe  pain  in  the  gastric  region,  pointing  to  a 
hyperesthesia  of  the  sensory  nerves,  which  may  probably  be  the  cause 
of  this  kind  of  vomiting.  Stiller  gives  the  following  points  which  are 
characteristic  of  vomiting  of  nervous  origin:  (i)  The  facility  of  the 
emesis.  (2)  The  independence  of  the  quality  and  quantity  of  the 
ingesta.  (3)  The  capriciousness  with  which  very  bizarre  articles  of 
diet  are  frequently  retained  to  the  exclusion  of  others.  (4)  Some- 
times the  elective  vomiting  of  certain  substances  which  seemingly  are 
separated  from  the  mixed  chyme.  (5)  The  carelessness  with  which 
the  patient  endures  the  habitual  sickness.  (6)  The  tolerance  of  the 
body  to  the  effect  of  inanition  caused  by  the  habitual  vomiting,  even 


NERVOUS    VOMITING.  757 

when  the  metaboHsm  is  much  reduced.  (7)  The  extraordinary  in- 
fluence of  the  sHghtest  external  and  internal  causes  that  act  on  mood 
or  temperament.  (8)  The  frequent  occurrence  of  emesis  when  no 
food  has  been  taken  and  the  stomach  is  apparently  empty.  (9)  The 
presence  of  other  nervous  symptoms  alternating  or  contemporaneous 
with  the  vomiting.  To  these  Boas  adds  (10)  the  absence  of  impor- 
tant secretory  or  motor  disturbances.  In  some  of  these  cases  the  vom- 
iting occurs  almost  every  day,  occasionally  after  each  meal.  In  other 
cases  the  attacks  occur  at  longer  or  shorter  intervals,  either  spon- 
taneously or  after  severe  influences  exerted  upon  the  psychical  sphere. 
Cases  have  been  repeatedly  observed  in  which  only  the  liquids  have 
been  expelled,  and  in  others  only  the  solids.  Sometimes  the  vege- 
table and  carbohydrate  foods  are  vomited  and  proteid  food  retained, 
or  vice  versa.  Nausea  and  retching  are  absent  in  the  vomiting  of 
h3"sterics,  which  occurs  without  any  exertion. 

Juvenile  vomiting  rarely  occurs  by  itself,  but  is  rather  an  expres- 
sion of  a  dyspepsia  developed  in  school-children  as  a  result  of  mental 
overexertion.  The  symptoms  are  the  following:  dyspeptic  com- 
plaints, gastralgia,  vomiting,  great  pallor,  dilation  of  pupils,  slowing 
of  the  pulse,  constipation.  In  all  of  these  cases  improvement  follows 
when  the  children  are  removed  from  school  and  allowed  to  rusticate 
in  the  fresh  country  air  (Leyden,  "Ueber  period.  Hrbrechen,"  etc., 
"Zeitschr.  f.  klin.  Med.,"  1882,  Bd.  iv,  S.  605). 

Reflex  Vomiting  in  a  More  Restricted  Sense.— Strictly  speaking, 
vomiting  is  almost  always  a  reflex  act,  and  the  separation  of  other 
forms  of  vomiting  from  reflex  vomiting  is  justifiable  only  on  didactic 
grounds.  There  is  hardly  an  organ  which  could  not  produce  this  form 
of  vomiting  when  it  is  in  a  state  of  irritation.  The  peripheral  irrita- 
tions causing  this  reflex  vomiting  are,  among  the  first,  those  which 
strike  the  sensory  and  motor  nerve-endings  in  the  esophagus,  the  pos- 
terior pharyngeal  wall,  the  epiglottis,  the  soft  palate,  and  the  root  of 
the  tongue.  All  organs  that  are  supplied  by  branches  of  the  vagus — 
so  particularly  the  abdominal  organs — may,  under  pathological  condi- 
tions, excite  an  attack  of  reflex  vomiting.  It  may  occur  as  a  result 
of  constipation,  meteorism,  lead  colic,  irritation  by  foreign  bodies, 
and  intestinal  parasites.  It  is  one  of  the  first  symptoms  of  strangu- 
lated hernia,  and  of  conditions  of  irritation  in  the  peritoneum.  Ab- 
scess of  the  liver,  perityphlitis,  renal  and  hepatic  colic  are  associated 
with  reflex  vomiting.  It  has  been  known  to  occur  by  the  invasion 
of  the  ascaris  lumbricoides  into  the  ductus  choledochus,  emboli  in  the 


758  NEUROSES   OF  THE  STOMACH. 

kidney,  liver,  pancreas,  and  spleen,  floating  kidney,  and  severe  con- 
cussion or  contusion  of  any  abdominal  organ.  Diseases  of  the  female 
sexual  organs  are  a  prolific  source  of  this  form  of  emesis.  It  is  not  the 
severe  anatomical  diseases  of  these  organs  that  most  often  cause  these 
attacks,  but  preferably  the  slight,  inconsiderable  affections.  Nor- 
mal menstruation  and  pregnancy  are  occasionally  accompanied  by 
emesis.  The  so-called  pernicious  vomiting  of  pregnancy  may  be 
caused  by  a  variety  of  conditions,  although  its  pathogenesis  is  still 
obscure.  When  vomiting  is  uncontrollable  in  a  female  in  whom  the 
evidences  of  pregnancy  are  unmistakable,  the  embryo  should  be  re- 
moved and  the  uterus  curetted  before  prostration  becomes  too  great. 
Fleischer  states  that  this  should  be  done  in  order  to  save  the  life  of  the 
mother  and  eventually  that  of  the  child  (I.  c,  p.  977) ;  the  pernicious 
vomiting  of  pregnancy  occurs,  however,  at  such  an  early  period  in  our 
experience  that  the  child  would  not  be  viable.  Every  form  of  severe 
vomiting,  when  it  continues  for  a  week  or  more,  will  eventually  pro- 
duce hematemesis  from  local  ischemias  produced  by  the  convulsive 
gastric  contractions  during  the  emesis.  In  a  patient  that  died  at  the 
Maryland  General  Hospital  in  April,  1897,  the  young  woman,  who 
was  undoubtedly  pregnant,  and  who  refused  to  be  curetted,  vomited 
and  purged  blood  in  the  second  week,  so  that  the  practitioner  who 
presented  her  for  admission  stated  that  she  had  undoubtedly  a  gastric 
ulcer.  At  the  autopsy,  which  occurred  three  weeks  after  the  begin- 
ning of  the  attack,  an  embryo  between  two  and  three  months  old  was 
found  within  the  uterus,  while  nowhere  in  the  stomach  could  a  lesion 
be  found  excepting  large  ecchymoses,  some  of  them  attaining  the 
size  of  a  five-cent  piece,  and  scattered  over  the  entire  surface  of  the 
stomach,  which,  in  our  opinion,  had  been  caused  by  the  intensely 
spastic  contractions  of  the  stomach,  producing  ischemia.  Displace- 
ments of  the  uterus,  pelvic  exudates,  parametritis,  inflammations 
and  ulcerations  of  the  uterine  mucosa,  myomata,  and  ovarian  dis- 
eases may  cause  reflex  vomiting,  which  is  much  rarer  with  the  diseases 
of  the  male  sexual  organs.  Nevertheless,  it  is  occasionally  observed 
with  injury  of  inflammations  of  the  testicles  and  in  epididymitis. 
Chronic  inflammation  about  the  nasal  mucous  membrane,  polypi,  and 
hyperplasia  of  the  upper  air-passages  have  been  recorded  as  produc- 
ing the  disease.  Eichhorst  has  repeatedly  observed  reflex  vomiting 
in  certain  individuals  on  hearing  very  shrill  tones.  Von  Troeltzsch 
has  called  attention  to  the  fact  that  irritation  of  the  external  auditory 
canal  may  cause  emesis. 


PROGNOSIS   AND    DIAGNOSIS    OF    NERVOUS    VOMITING.  759 

Prognosis  of  Nervous  Vomiting. — The  prognosis  will  vary  with 
the  fundamental  causative  disease.  Gastric  crises,  when  they  occur 
in  advanced  tabes,  may  cease  entirely  after  a  time,  although  the  fun- 
damental disease  continues  and  even  becomes  worse.  Periodical 
vomiting,  which  occurs  after  insignificant  disturbances  in  other  or- 
gans, which  get  well  without  difficulty,  may  stubbornly  persist  after 
the  fundamental  disease  has  been  cured.  The  prognosis  is  favorable 
whenever  the  causes  can  be  recognized  and  completely  removed.* 

Diagnosis. — The  majority  of  the  forms  of  nervous  vomiting  can  be 
determined  after  an  exhausting  examination  of  the  entire  body,  the 
urine,  the  blood,  and  gastric  contents.  A  careful  study  of  the  pre- 
vious history  is  indispensable.  Nervous  vomiting,  as  has  been  said, 
may  be  in  rare  cases  an  idiopathic  vagus  neurosis  (Ley den),  but  in 
most  cases  some  palpable  cause  for  the  vomiting  can  be  detected. 
Prominent  among  these  are  dislocated  kidneys,  hdyronephrosis, 
uterine  and  ovarian  diseases,  entozoa,  and  nicotin  poisoning.  A  care- 
ful examination  of  the  fundus  of  the  eyes,  of  the  ears,  and  of  the  nose, 
mouth,  pharynx,  and  larynx  should  never  be  omitted. 

Treatment. — Whenever  possible,  the  treatment  must  be  directed 
to  the  underlying  causal  disease.  When  the  various  morbid  states  of 
other  organs,  which  have  been  mentioned  in  the  etiology  and  symp- 
tomatology, can  be  excluded  after  application  of  all  methods  of  diag- 
nostic technic,  only  then  is  a  purely  symptomatic  treatment  justifia- 
ble. Hysteria  and  neurasthenia  are  to  be  met  by  hydropathic  pro- 
cedures, or  by  absolute  rest,  abstention  from  mental  and  emotional 
excitement,  and  a  sojourn  in  the  mountains  or  at  the  seashore.  In 
most  cases  the  greatest  possible  rest  and  strict  avoidance  of  psychi- 
cal disturbances  will  be  indispensable.  Gastralgic  pains  and  hyper- 
esthesia can  be  relieved  by  a  hot  cataplasm  on  the  stomach,  but  the 
application  of  the  galvanic  current  anode  on  the  stomach  or  in  the 

*  A  case  of  severe  nervous  vomiting  which  had  persisted  for  two  years  under  my 
observation  defied  all  treatment :  electricity,  lavage,  Weir-Mitchell  rest-cure,  sedatives. 
All  foods  were  vomited.  For  two  months  a  membranous  colitis  prevented  rectal  feeding, 
and  the  life  of  the  patient  was  maintained  by  hypodermic  injections  of  sterile  olive  oil. 
Periodical  pyloric  spasm  existed  at  the  same  time.  Professor  Howard  A.  Kelly,  after  an 
exploratory  incision,  found  nothing  abnormal  with  the  stomach  or  intestines,  no  adhesions, 
pelvic  organs,  liver,  and  spleen  normal.  But  the  pylorus  seemed  somewhat  smaller  than 
it  should  be,  and  a  pyloroplastic  operation  was  done  (January  19,  1 900).  It  is  too  early 
to  judge  of  the  effects  of  this  operation,  but  one  week  thereafter  the  vomiting  had  not  re- 
turned. The  case  is  mentioned  only  to  show  that  very  severe  cases  of  nervous  vomiting 
may  exist  without  observable  anatomical  lesions  ;  may  endanger  life  by  'progressive 
emaciation. 


76o  NEUROSES    OF   THE    STOMACH. 

stomach,  and  cathode  alternately  on  the  sternum  or  spinal  column 
will  be  more  efficacious.  The  internal  gastric  douching  with  warm 
water,  and,  as  we  have  found,  spraying  of  the  inside  of  the  stomach 
with  solutions  of  menthol  and  cocain,  are  also  generally  followed  by 
cessation  of  the  pain.  In  vomiting  of  pregnancy  rectal  feeding  and 
six  grains  of  the  basic  orexin  in  a  gelatin  capsule  three  or  four  times 
a  day  should  be  tried  first,  but  cureting  of  the  uterus  should  not  be 
delayed  too  long.  The  following  formula  we  have  found  efficacious 
in  the  treatment  of  this  form  of  vomiting  of  the  non-pernicious  type : 

R .      Cerii  oxalatis,       4.0  gr.  Ix 

Cocain  hydrochlor., 0.2  g""-  iij 

Menthol, 0.8  gr.  xij 

Bismuth  salicylatis, 4.0  ^j 

Elixir  simpL, q.  s.  180.0  f^vj.  M. 

SiG. — One-half  fluidounce  on  an  empty  stomach  four  times  daily. 

Hypodermic  injection  of  |^  of  a  grain  of  morphin,  together  with  y^o" 
of  a  grain  of  atropin  sulphid,  proved  helpful  in  a  number  of  cases. 

The  idiosyncrasy  of  the  patient  concerning  diets  should  be  care- 
fully studied.  A  priori,  "no  diet  can  be  suggested  that  shall  be  uni- 
versally applicable  to  all  cases."  The  ingestion  of  liquids  must,  as  a 
rule,  be  very  much  limited,  and  thirst  relieved  by  colon  enemata.  If 
every  meal  is  vomited,  it  is  best  not  to  permit  the  ingestion  of  larger 
quantities  of  food,  but  simply  to  give  nourishment  in  very  small 
quantities — iced  milk,  champagne,  cold  tea  or  coffee,  or  egg-albumen 
with  brandy,  or  clam  bouillon  in  tablespoonful  doses.  Superacidity 
must  be  treated  according  to  principles  laid  down  in  the  chapter  on 
this  subject.  When  there  is  abnormal  hyperesthesia  of  the  stomach, 
it  is  well  to  feed  the  patient  by  rectal  enemata  for  about  a  week  to 
ten  days,  according  to  methods  described  in  the  chapter  on  Dietetics. 
The  most  effective  sedative  that  we  have  is  morphin,  particularly 
the  hypodermic  injection  of  |^  of  a  grain,  together  with  yg-Q-  of  a  grain 
of  atropin  sulphate.  The  following  suppositories  are  useful  when  we 
do  not  wish  to  create  an  adaptation  to  morphin : 

Be.     Extract,  belladonnje, 0.2  g^"-  "j 

Codein  phosphatis, 0.8  gr-  xij 

Butyr.  cacao, q.  s. 

Supposit.  No.  xii. 

SiG. — Insert  one  suppository  every  two  hours  during  the  attack. 

When  the  nervous  vomiting  persists,  even  during  the  night,  the 
bromids,  together  with  chloral  hydrate,  are  of  approved  efficacy.  I 
am  in  the  habit  of  giving  thirty  grains  of  bromid  of  strontium  with  ten 


TREATMENT   OE    NERVOUS   VOMITING.  76 1 

grains  of  chloral  in  peppermint  water,  repeated  every  three  hours 
until  sleep  supervenes.  We  have  also  found  the  following  combina- 
tion to  be  a  reliable  means  of  combating  this  neurosis : 

Be.     Menthol, I.o  gr.  xv 

Cocain  hydrobromatis,   i 0.4  gr.  vj 

AquK  chloroformi, 120.0  ^^^^ 

Spin  vini  gallic 60.0  f^ij-  M. 

SiG. — One  tablepoonful  three  times  a  day,  largely  diluted. 

In  the  treatment  of  the  gastric  crises  Boas  has  found  that  iodid  of 
potassium  and  bromid  of  sodium  exert  very  favorable  influences  in 
diminishing  the  frequency  and  intensity  of  the  attacks.  The  use  of 
the  constant  current,  with  the  anode  within  the  stomach  and  the 
cathode  over  the  spinal  cord  in  the  cervical  region,  is  generally  fol- 
lowed by  a  very  marked  palliative  effect.  Chloroform,  three  to  five 
drops  given  on  sugar,  ammoniated  tincture  of  valerian,  twenty-five 
drops  p.  r.  n.,  and  the  compound  spirits  of  ether,  fifteen  to  twenty 
drops  p.  r.  n.,  might  be  tried,  but  in  our  experience  they  are  rarely 
efficacious.  Basch  (I.  c.)  made  comparative  therapeutic  studies 
with  cerium  oxalate,  strychnin,  and  antipyrin  in  the  treatment  of 
tabic  gastric  crises.  The  results  were  not  encouraging  with  any  of 
these.  For  the  control  of  vomiting  in  tabic  gastric  crises  the  follow- 
ing is  about  the  most  effective  combination  I  have  experience  with : 

Be .     Strontium  bromid, 

Sodium  bromid,      aa     3.0  gr.  xlv 

Morphia  sulphat., 0.065  §•"•  J 

Essentiae  pepsin., 200.0  ^viss.  M. 

SiG. — One  tablespoonful  every  two  hours. 


INSUFFICIENCY  OR  INCONTINENCE  OF  THE  CARDIA. 
Incontinence  of  the  cardia,  due  to  paresis  or  paralysis  of  the  motor 
nerves  of  the  ring  muscle,  is  a  comparatively  rare  malady,  though 
somewhat  more  frequent  than  that  of  the  pylorus.  It  appears  either 
as  an  independent  disease,  or  as  a  partial  or  resultant  phenomenon 
of  other  neuroses.  The  relaxation  of  the  cardia  produces  an  effect 
directly  opposite  to  that  of  cramp  of  the  cardia.  While  the  latter, 
as  is  well  known,  prevents  the  removal,  by  eructation,  of  the  air  and 
gases  introduced  into  the  stomach  during  meals,  as  well  as  that  of 
liquid  or'solid  contents  of  the  stomach,  insufficiency  of  the  cardia,  on 
the  other  hand,  much  facilitates  it.  When  the  relaxation  of  the 
cardia  is  accompanied  by  an  increased  irritation  of  those  motor  nerves 


762  NEUROSES    OF    THE   STOMACH. 

which  innervate  the  dilator  of  the  cardia,  so  that  b}-  the  spasm  of  the 
latter  the  esophageal  orifice  of  the  stomach  is  actively  enlarged, 
energetic  peristalsis  of  the  stomach,  with  the  additional  influence 
of  the  abdominal  pressure,  will  raise  portions  of  the  gastric  contents 
into  the  esophagus  and  even  into  the  mouth. 

The  firmness  of  the  cardial  closure,  even  under  normal  circum- 
stances, seems  to  vary  greatly  in  different  individuals.  While  many 
persons  vomit  only  with  diflSculty, — since  the  resistance  at  the  esoph- 
ageal orifice  of  the  stomach  is  greater,  so  that  they  have  to  make 
use  of  almost  all  known  remedies  and  devices  in  order  to  overcome  it, 
— and  even  then  eject  only  a  portion  of  the  contents  of  the  stomach, 
others  vomit  with  exceeding  ease,  and  they  succeed,  with  only  a  mod- 
erate contraction  of  the  abdominal  muscles,  in  empt3dng  the  stomach 
entirely  through  vomiting.  In  one  and  the  same  individual  the  clo- 
sure of  the  cardia  may  van,'  at  different  times.  At  times  small  quan- 
tities of  ingesta  come  up  again  into  the  mouth  after  eating,  while  at 
other  times,  with  the  same  food  and  the  same  fullness  of  the  stomach, 
this  does  not  occur. 

If  only  small  quantities  of  the  contents  of  the  stomach  come  up 
into  the  mouth,  now  and  then,  this  does  not  yet  constitute  an  abnor- 
mal condition;  one  should  only  consider  it  abnormal  when  large 
quantities  of  ingesta  come  up  after  eating,  and  when  this  is  repeated 
frequently,  almost  regularly  ever}'  day  for  a  considerable  period  of 
time.  If  the  masses  which  come  up  are  expectorated,  the  whole  pro- 
cess is  called  regurgitation ;  but  if,  on  the  other  hand,  they  are  swal- 
lowed again,  it  is  raUed  rumination  (merycism,  remastication),  even 
when  the  regurgitated  foods  are  not  chewed  again,  which  is  obsen'ed 
in  a  small  number  of  patients. 

Concerning  the  causes  of  regurgitation  and  rumination,  opinions 
still  differ  greatly  at  the  present  time.  Some  authors  trace  both  con- 
ditions to  a  permanent  relaxation  of  the  cardia,  but  the  presence  of 
the  deglutition  sounds  is  an  argument  against  a  permanent  incon- 
tinence, according  to  Ewald;  other  authors  assume  a  temporary 
insufficiency  of  the  cardia,  and  still  others,  in  addition,  an  increased 
irritation  of  the  motor  nerv'es — and  eventually  also  of  the  sensory 
nerves — of  the  stomach.  According  to  AI.  Rosenthal,  regurgitation 
and  rumination  are  caused  by  an  increased  irritability  of  the  vagus, 
and  with  this  also  an  inceased  irritability  of  the  motor  nerves  leading 
from  it  and  supplying  the  dilator  cardiae,  which  causes  a  spasm  of  the 
latter,   and  through  this  an  active  enlargement  of  the  esophageal 


REGURGITATION — THERAPEUTICS.  763 

orifice  of  the  stomach.     Whether  the  disease  is  of  central  or  periph- 
eral origin  is  at  present  also  impossible  to  decide. 

Regurgitation. — At  a  longer  or  shorter  period  after  meals  large 
quantities  of  the  liquid  and  solid  contents  of  the  stomach  are  at  first 
involuntarily  brought  up  again  into  the  mouth,  and  are  then  ex- 
pectorated. With  protracted  duration  of  regurgitation  the  patient 
generally  learns  how  to  facilitate  the  ascension  of  the  ingesta  by 
means  of  rather  severe  contractions  of  the  musculature  of  the  abdo- 
men. According  as  regurgitation  takes  place  in  the  first  or  second 
period  of  the  digestion  of  the  stomach,  the  regurgitated  food  particles 
have  either  the  same  taste  as  in  eating,  or  they  taste  sour  (HCl)  or 
bitter  (peptone).  Regurgitation  is  not  easily  mistaken  for  vomiting, 
since  the  sensations  of  nausea  experienced  before  and  after  the  latter 
are  entirely  lacking  with  regurgitation.  Regurgitation  takes  place 
without  any  especial  exertion  on  the  part  of  the  patients,  and  is  easily 
distinguished  from  the  retching  forth  of  foods  previously  eaten,  in 
cases  of  stenosis  or  the  formation  of  diverticula  in  the  esophagus — 
that  is,  from  the  rising  up  of  the  same  into  the  mouth,  when  the  diver- 
ticulum is  full  and  runs  over.  The  difficulties  of  deglutition,  the  re- 
sult of  sounding  the  esophagus,  as  well  as  the  constant  absence  of 
hydrochloric  acid  in  the  regurgitated  masses,  make  a  sure  dift'erentia- 
tion  of  the  two  first-mentioned  diseases  possible.  Most  patients  are 
able  to  suppress  regurgitation,  but  in  a  few  cases  they  do  not  succeed 
in  this,  however  much  they  tr}^  If  copious  quantities  of  the  contents 
of  the  stomach  are  regurgitated  in  quick  succession  and  are  expec- 
torated, the  general  nutrition  may  suffer  considerably ;  but  generally 
these  patients  have  a  very  hearty  appearance.  Other  nervous  dis- 
turbances— signs  of  hysteria  or  neurasthenia — may  be  present  coinci- 
dently.  With  protracted  duration,  regurgitation  may  develop  into 
rumination. 

The  prognosis  is  generally  favorable  with  regurgitation,  since  the 
state  of  nutrition  remains  good,  and  if  disturbances  of  nutrition  ap- 
pear, the  patient  often  can  be  induced  to  swallow  the  ingesta  which 
have  risen  into  the  mouth  and  to  energetically  prevent  their  coming 
up  again. 

Therapeutics. — Regurgitation  is  promoted  by  hasty  eating  and 
quick  swallowing  of  insufficiently  chewed  foods,  especially  when  the 
latter  are  of  difficult  digestion ;  a  diet  should,  therefore,  be  prescribed 
which  is  easily  digestible,  and  the  patients  should  be  directed  to  eat 
slowly  and  chew  thoroughly.     Gladstone's  suggestion  is  to  give  each 


764  NEUROSES   OF   THE   STOMACH. 

morsel  of  food  one  bite  or  grind  for  ever^^  tooth  in  the  mouth — i.  e.,  32 
— before  it  is  swallowed.  It  is  best  for  the  patients  to  eat  in  the  com- 
pany of  such  persons  whose  good  opinion  they  value,  so  that  they 
avoid  expectorating  the  ingesta  which  have  risen  into  the  mouth,  and 
will  rather  swallow  them  again  endeavoring  to  combat  regurgitation 
to  the  utmost  of  their  power.  If  indications  of  hysteria  or  neurasthe- 
nia can  be  shown,  these  diseases  are  first  to  be  treated.  In  stubborn 
cases  the  swallowing  of  small  pieces  of  ice  is  recommended  (Alt), 
which  may  refiexly  induce  the  musculature  of  the  cardia  to  contract. 
In  addition,  massage  of  the  epigastrium,  internal  and  external  gal- 
vanization and  faradization,  as  well  as  internal  administration  of 
strychnin  nitrate  (0.003-0.006)  are  indicated.  The  galvanic  current 
should  be  applied  in  the  same  manner  as  in  cardiospasm. 


RUMINATION,   OR   MERYCISM. 

Patients  afflicted  with  this  neurosis  return  the  ingesta  from  the 
stomach  through  the  esophagus  back  into  the  mouth  sooner  or  later 
after  the}^  have  been  swallowed.  This  is  not  only  done  without 
nausea,  but  apparently  with  a  certain  enjoyment.  The  raised  food 
is  rechewed,  and  either  swallowed  again  or  expectorated.  This  oc- 
curs habitually  several  hours  after  meals  and  without  the  least  exer- 
tion. Rumination  in  the  human  subject  has  been  known  for  a  long 
time.  Fabricius  Ab.  Aquapendente  described  the  disease  in  161 8. 
As  the  knowledge  of  physiology  of  older  practitioners  was  very  lim- 
ited, and  the)^  had  no  conception  of  the  functions  and  mechanism  of 
gastric  digestion,  the  most  peculiar  hypotheses  were  developed  in 
explanation  of  this  very  interesting  neurosis.  It  was  firmly  believed 
that  ruminants  descended  from  parents  with  horns,  or  that  they  at 
least  had  a  horned  father,  or  had  been  nursed  from  the  udder  of 
ruminating  horned  animals.  It  was  also  believed  that  the  stomach 
of  human  ruminants  was  divided  into  several  sections  by  partitions, 
as  we  find  them  in  cattle.  After  it  was  found  at  autopsies  that  rumi- 
nants possessed  stomachs  of  the  same  structure  as  all  other  human 
beings,  the  profession  gradually  accepted  the  neurotic  explanation  of 
the  malady. 

Etiology. — A  neuropathic  constitution  is  a  frequent  factor  in  the 
development  of  rumination.  Heredity  seems  to  have  some  effect  in 
the  matter,  as  ruminating  fathers  have  been  known  to  have  ruminat- 
ing children.     The  element  of  imitation  and  suggestion  can,  however, 


ETIOLOGY    AND    SYMPTOMATOLOGY    OF    RUMINATION.  765 

not  well  be  eliminated  under  this  question  of  heredity.  Freund  and 
Korner  have  described  a  case  in  which  two  children  developed  this 
habit  in  imitation  of  their  ruminating  governess.  The  disease  seems 
to  be  more  frequent  in  men  than  in  women.  It  occurs  in  all  classes  of 
society  and  at  all  ages.  The  following  are  some  of  the  causes  assigned 
to  rumination:  Sexual  excesses,  masturbation,  fear,  terror,  anger, 
psychical  irritations,  and  the  very  hasty  deglutition  of  badly  masti- 
cated food,  particularly  when  it  exists  exclusively  of  vegetables,  in- 
jury to  the  epigastrium,  achlorhydria,  obstinate  constipation,  and 
gastroenteritis.  It  is  claimed  by  Dehio  that  whooping-cough  may 
be  followed  by  this  disease ;  this  is  very  plausible,  because  pertussis 
brings  on  frequent  vomiting,  and  thereby  an  incontinence  of  the 
cardia.  Although  the  disease  has  been  known  to  occur  in  persons 
of  high  intellectuality,  a  large  number  of  ruminating  patients  belong 
to  the  class  of  neurasthenics,  and  hysterical,  hypochondriacal,  epilep- 
tic, anemic,  choreic,  and  idiotic  individuals.  The  disease  has  been 
studied  by  Bourneville  and  Seglas,  Dehio,  Alt,  Boas,  Bear,  Ducasse, 
Decker,  Einhorn,  Oser,  Ponsgen,  Johannessen,  Lebert,  M.  Rosen- 
thal, and  E.  Singer. 

In  the  "N.  Y.  Med.  Record"  for  June  12,  1896,  Dr.  H.  A.  Minas- 
sian  reports  an  interesting  case  of  merycism  with  achlorhydria  and 
hyperperistalsis  which  was  cured  by  hydrochloric  acid,  exclusion  of 
fluids,  and  exercise  of  self-control.  "  In  the  same  journal  for  July  lo, 
1897,  Andrew  Halliday,  M.B.,  a  physician  of  Nova  Scotia,  who  per- 
sonally has  the  power  of  regurgitation  and  rumination  at  will,  gives 
the  analysis  of  his  own  stomach-contents :  Forty-five  to  sixty  min- 
utes after  an  Ewald  test-meal  the  total  acidity  was  45  to  55.  The  free 
HCl  was  o.  1 24  to  o.  1 604  per  cent.  His  motility  seems  normal.  These 
two  cases  suffice  to  show  the  variability  of  the  state  of  secretion  and 
motility  in  merycism. 

Symptomatology. — The  regurgitation  of  ingesta  from  the  stomach 
into  the  mouth  is  usually  at  first  voluntary,  but  later  on  involuntary. 
The  rumination  differs  from  simple  regurgitation  in  that  the  raised 
food  is  expectorated  in  the  latter  disease,  but  is  swallowed  again 
in  the  former.  The  ascent  of  the  food  from  the  stomach  causes  a 
pleasurable  sensation  to  these  patients,  and  they  assist  the  act  by 
bringing  into  effect  the  pressure  of  their  abdominal  muscles.  In 
severe  cases  the  rumination  occurs  after  every  meal,  and  lasts  cither 
only  for  the  first  hour  or  for  five  or  six  hours.  The  condition  of  the 
secretory  function  is  variable.     Jiirgensen  found  no  free  HCl,  Bear 


766  NEUROSES  OF  the;  stomach. 

and  Boas  found  subacidity,  while  Alt  demonstrated  hyperacidity  in 
one  of  his  cases.  In  some  patients  secretion  was  found  to  be  normal. 
In  three  of  such  cases  I  observed  that  the  state  of  the  secretion  varied, 
as  expressed  in  the  chemical  analysis  of  the  raised  masses  according 
to  the  time  after  the  ingestion  in  which  they  were  regurgitated,  and 
the  combining  power  for  HCl  which  the  particular  food  possessed.  If 
they  were  regurgitated  immediately  after  the  meal,  they  were  faintly 
acid  or  neutral,  contained  no  free  HCl  nor  ferments,  which,  however, 
were  present  within  forty-five  minutes  of  the  first  ingestion  of  food. 
It  is  probable  that  many  of  the  discrepancies  concerning  the  state  of 
the  secretion,  as  stated  by  the  various  authors  mentioned,  can  be  ex- 
plained on  the  same  grounds.  Alt  has  suggested  a  very  interesting 
theory  in  explanation  of  the  ruminating  habit  (' '  Berlin,  klin.  Wochen- 
schr.,"  Bd.  lxxxviii,  Nos.  26  and  27):  he  suggests  that  the  object 
of  the  act  may  be  the  correction  of  defective  chewing  and  insalivation 
of  the  food,  and  the  hyperacidity  caused  thereby.  Acting  accord- 
ingly, Alt  treated  his  patient  with  alkalies,  and  claims  to  have  found 
that  the  case  ruminated  less  frequently  and  by  and  by  could  suppress 
the  habit.  Boas  ("Berlin,  klin.  Wochenschr.,"  1886,  No.  831)  has 
published  a  case  of  rumination  with  subacidity,  and  in  this  case  im- 
provement followed  the  administration  of  HCl.  According  to  Ein- 
horn,  but  106  cases  of  this  malady  have  been  described  up  to  1896, 
which  cases  occurred  chiefly  among  the  professional  and  educated 
classes — physicians,  lawyers,  and  philologists.  This  observation  was 
also  made  in  a  report  by  Johannessen  ("Zeitschr.  f.  klin.  Med.,"  Bd. 
X,  S.  274). 

The  following  is  a  brief  account  of  a  case  occurring  in  my  private  practice: 
A.  F.,  aged  thirty-eight,  mother  has  been  a  highly  nervous  woman,  much 
afflicted  with  insomnia  and  neuralgia  ;  father  died  at  the  age  of  fifty-six  from 
Bright's  disease.  He  was  a  very  irascible  and  eccentric  man.  A.  F.  has  had 
no  severe  disease,  except  gout  four  years  ago.  He  is  a  pianist  of  exceptional 
ability,  and  has  played  in  foreign  countries  as  well  as  in  the  larger  cities  of 
the  United  States.  Ordinarily  and  when  in  a  quiet  frame  of  mind  he  rarely 
ruminates,  but  when  he  gives  instruction,  particularly  when  he  has  to  perform 
at  a  concert,  or  at  other  times  when  he  is  emotionally  excited  or  disturbed,  he 
begins  to  raise  food  into  his  mouth,  which  he  at  first  swallows  for  about  two 
hours.  He  confesses  that  he  chews  the  food,  and  actually  enjoys  it,  but  at  the 
expiration  of  two  hours  the  muscles  of  mastication  become  so  exhausted  that 
he  can  no  longer  chew  the  raised  masses.  He  would  then  like  to  put  an  end 
to  the  ruminating,  or  rather  to  the  rising  of  the  food,  but  then  can  not  stop  it, 
as  it  persists  in  coming  up  from  his  stomach.  He  then  terminates  the  rumina- 
tion by  voluntarily  evacuating  his  stomach  through  vomiting,  which  he  accom- 
plishes very  easily. 


PROGNOSIS   AND   TREATMENT   OF    RUMINATION.  767 

The  masses  begin  to  ascend  within  ten  to  fifteen  minutes  after  a  meal,  and 
are  then  very  faintly  acid.  He  is  also  aware  that  they  begin  to  taste  salty  sour, 
as  he  calls  it,  forty-five  minutes  to  an  hour  after  the  meal.  The  total  acidity 
one  hour  and  a  quarter  after  a  meal,  as  judged  from  the  regurgitated  masses, 
is  70;  free  HCl  30.  Erythrodextrin  present;  achroodextrin  present.  Gas- 
tric motility,  as  determined  by  Hemmeter's  method,  is  evidently  exaggerated. 
Physical  examination  of  the  thoracic  and  abdominal  organs  negative.  Urine 
negative.  Examination  of  bloqfd  negative.  On  one  occasion  this  patient  had 
not  ruminated  for  three  weeks,  when  the  time  came  for  him  to  fulfil  an  engage- 
ment at  a  concert.  The  author,  for  the  sake  of  study,  was  present  when  he 
took  his  supper  on  the  evening  of  this  concert.  Within  fifteen  minutes  after 
the  supper  we  observed,  by  the  movements  of  his  throat,  he  had  begun  his  old 
bad  habit,  which  kept  up  during  the  entire  evening,  and  was  plainly  observable 
while  he  was  performing  at  the  piano  during  the  concert. 

Atony  and  dilation  may  be  present,  together  with  rumination,  and 
the  state  of  the  motility  seems  to  vary  as  much  as  that  of  secretion. 
The  general  nutrition  is  not,  as  a  rule,  affected,  although  the  disease 
may  have  existed  a  long  time;  but  when  the  patients  persistently 
spit  out  the  ascending  masses  of  food,  instead  of  swallowing  them 
again,  or  when  severe  disturbances  of  secretion  and  motility  exist, 
the  patients  rapidly  lose  strength  and  weight.  According  to  von 
Hacker  and  G.  Singer,  an  insufficiency  of  the  cardia,  and  a  dilation  of 
the  esophagus  immediately  above  the  cardia,  may  be  caused  by 
mechanical  expansion,  resulting  from  the  regurgitation  of  large  bits 
of  food.  This  esophageal  expansion  has  been  demonstrated  by  these 
authors  with  the  esophagoscope. 

Prognosis. — This  is  not  a  serious  disease,  as  the  general  nutrition 
remains  good,  and  if  the  patient  really  does  begin  to  suffer,  he  may 
be  relieved  by  a  rational  psychical  and  symptomatic  treatment,  par- 
ticularly if  the  patient  himself  will  aid  the  therapeutic  measures  by 
self-control.  The  diagnosis  presents  no  difficulties  whenever  the 
physician  can  observe  a  patient  in  the  act  of  rumination ;  regurgita- 
tion and  emesis  imply  the  spitting  out  of  food,  and  are  always  asso- 
ciated with  nausea  or  some  other  unpleasant  sensation. 

Treatment. — Medicinal  treatment  in  this  disease  is  of  little  value. 
The  state  of  the  secretions  should  be  carefully  determined,  and  sub- 
acidity  or  achylia  corrected  by  the  administration  of  HCl,  and  hyper- 
chylia  by  the  use  of  calcined  magnesia  and  bicarbonate  of  sodium. 
Korner  is  enthusiastic  on  the  value  of  small  pieces  of  ice  given  directly 
after  meals.  The  stomach-tube  has  been  used  for  the  lavage  and 
artificial  feeding,  but  the  relief  has  been  only  temporar^^  The  phy- 
sician should,  however,  in  all  cases  insist  on  slow  eating  "and  careful 


768  NEUROSES   OF   THE   STOMACH. 

chewing ;  the  food  should  be  easily  digestible  and  largely  composed  of 
gruels  and  diet  of  a  soft  consistency.  The  patient  should  always 
take  his  meals  in  the  presence  of  persons  for  whom  he  has  considera- 
ble respect,  and  who  understand  to  oppose  the  morbid  habit  with 
kindness  and  yet  with  emphatic  persistence.  The  success  of  the 
treatment  will  depend  upon  the  will-power  of  the  patient  himself. 
Whenever  the  patient  feels  a  desire  to  ruminate,  he  should 
be  prompted  to  resist  the  temptation  with  all  the  self-control  at  his 
command.  He  should  be  guarded  against  using  the  contraction  of 
the  abdominal  muscles  to  assist  the  act.  Ponsgen,  Boas,  and  Bin- 
horn  report  permanent  cures  resulting  from  such  persistent  auto- 
suppression.  A  trial  might  be  made  with  the  intragastric  use  of  the 
faradic  and  galvanic  currents.  Hydropathic  methods  are  sometimes 
useful.  In  one  case  observed  by  myself,  in  which  every  meal  was 
persistently  ruminated,  I  carried  out  rectal  alimentation  for  twelve 
days,  not  allowing  anything  to  enter  the  stomach  during  this  time. 
Since  then  nearly  two  years  have  elapsed  and  rumination  has  not  thus 
far  returned.  I  hesitate  in  attributing  this  recovery  to  the  rectal 
alimentation,  although,  of  course,  it  was  impossible  for  the  patient  to 
regurgitate  and  ruminate  when  no  food  was  contained  in  the  stomach. 
However,  the  psychical  effect  of  hospital  treatment,  the  entirely  new 
surroundings,  and  attendance  by  intelligent  nurses,  the  constant  rest 
in  bed,  may  have  contributed  as  much  as  the  rectal  feeding  toward 
the  recovery.  In  another  case  the  author  cured  the  patient  by  giving 
ten  grains  of  quinin  after  each  meal.  The  good  result  is  not  attrib- 
uted to  the  antimalarial  effect,  but  rather  to  the  fact  that  the  quinin 
rendered  the  food  so  disgustingly  bitter  that  the  patient  suppressed 
the  regurgitation.  Rossier  claims  to  have  cured  one  case  by  muriate 
of  morphin,  and  another  by  large  doses  of  opium.  In  my  experience 
these  remedies  have  been  useless. 


INSUFFICIENCY   OR   INCONTINENCE   OF   THE   PYLORUS. 

It  has  been  known  for  a  long  time  that  an  insufficiency  or  incon- 
tinence of  the  pylorus  may  be  caused  by  organic  diseases  of  the  stom- 
ach and  intestines,  by  carcinoma  and  ulcer,  by  bringing  about  a  par- 
tial or  complete  obliteration  or  carcinomatous  infiltration  of  the  annu- 
lar muscle,  so  that  the  latter  becomes  incapable  of  functioning ;  or  it 
may  be  caused  by  a  stenosis  of  the  duodenum  leading  to  advanced 
dilation  of  the  initial  part  of  the  same.     Attention  was  first  called  by 


INSUFFICIENCY   OR   INCONTINENCE    OF    THE   PYLORUS.  769 

Ebstein  to  those  interesting,  though  vety  rare,  cases  of  insufficiency, 
which  appear,  in  the  absence  of  anatomical  changes,  genuine  neuroses 
— paralysis  of  the  motor  nerves  of  the  annular  muscle.  It  had  been 
previously  observed  by  Ebstein  as  a  concomitant  phenomenon  of 
myelitis  due  to  compression,  and  also  in  hysteria  and  gout;  but  it 
may,  perhaps,  occur  also  as  an  idiopathic  malady.  If  the  muscular 
insufficiency  is  confined  to  the  pylorus,  then  the  foods  and  liquids, 
according  to  the  degree  of  the  insufficiency,  either  remain  a  very  much 
shorter  time  than  usual  in  the  stomach,  or  enter  the  intestines  imme- 
diately after  their  ingestion.  The  nutriments  then  are  not  at  all  di- 
gested in  the  stomach,  or  only  to  a  slight  degree,  so  that  the  whole, 
or  almost  the  whole,  burden  of  digestion  falls  upon  the  intestine. 
Since,  however,  repeated  experiments  upon  human  beings  and  ani- 
mals have  proved  that  the  intestine,  in  normal  conditions,  may  en- 
tirely make  up  for  the  lack  of  digestion  in  the  stomach— and  the  ex- 
perience gained  from  the  treatment  of  persons  that  have  undergone  a 
resection  of  the  pylorus  confirms  this, — therefore  even  with  protracted 
duration  of  the  pyloric  insufficiency  disturbances  of  nutrition  gen- 
erally fail  to  appear,  especially  when  an  easily  digestible  diet  is  pre- 
scribed, suitable  to  the  malady,  and  provided  that  the  intestinal 
functions  are  normal. 

The  symptoms  of  pyloric  insufficiency  are,  in  brief,  the  following — 
viz. :  If  frequent  vomiting  and  belching  existed,  these  suddenly  cease 
after  the  setting  in  of  the  insufficiency.  If  rather  large  particles  of 
food  get  into  the  intestine  which  mechanically  irritate  its  mucous 
membrane  more  than  usual,  then  the  increased  peristalsis  may  cause 
diarrhea.  This  may  also  be  brought  about  by  very  cold  or  very  hot 
foods  or  drinks,  which  are  gradually  warmed  or  cooled  by  the  stom- 
ach, as  the  case  may  be,  before  their  entrance  into  the  intestine, 
when  the  closure  of  the  pylorus  is  normal.  If  a  quantity  of  air  was 
swallowed  with  the  foods,  or  if  drinks  rich  in  carbonic  acid  have  been 
imbibed  (beer,  seltzer  water,  champagne),  a  very  acute  tympanites  of 
the  intestine  may  develop  from  the  escape  of  air  or  carbonic  acid  gas. 

According  to  Ebstein,  one  can  not  succeed  in  distending  the  stom- 
ach with  the  artificial  production  of  carbon  dioxid  in  the  organ  by 
acid,  tartrate  and  sod.  bicarb.,  one  teaspoonful  of  each  in  4  ounces  of 
water  in  separate  tumblers;  but  Ewald,  Boas,  and  other  authors 
justly  contend  that  this  evidence  is  not  conclusive ;  since,  even  when 
the  musculature  of  the  pylorus  functions  in  a  normal  manner,  every 
attempt  at  distending  the  stomach  by  means  of  gases  niay  remain 


770  ne;uroses  of  the  stomach. 

unsuccessful,  because  the  amount  of  the  gases  formed  is  too  small. 
Further,  with  an  empty  stomach  the  pylorus  (Kussmaul)  is  normally 
so  relaxed  that  a  portion  of  the  carbonic  acid  gas  may  easily  pass  over 
into  the  intestine,  without  the  presence  of  any  real  insufficiency. 
This  source  of  error  may,  however,  be  removed  by  letting  the  patient 
eat  a  test-breakfast  before  the  distention  of  the  stomach  (Fleischer), 
since  then,  under  normal  circumstances,  the  closure  of  the  pylorus 
becomes  so  firm  that  the  carbonic  acid  gas  set  free  can  not  at  once 
escape  into  the  intestine ;  or  if,  instead  of  CO2,  air  is  forced  into  the 
stomach  by  means  of  a  tube  and  a  pump,  increasing  the  supply  ac- 
cording to  necessity.  If  the  air  passes  quickly  into  the  intestine,  the 
inflated  ascending  colon  appears  as  a  thick  swelling  on  the  right  side 
of  the  abdomen.  For  a  proof  of  the  purely  nervous  origin  of  insuffi- 
ciency it  is  necessary  to  exclude  the  above-mentioned  diseases  of  the 
stomach  and  intestine,  and  such  organic  diseases  of  the  stomach  as 
chronic  gastritis,  which  probably  bring  about  a  serous  infiltration  of 
the  annular  muscle,  and  may  lead  to  a  temporary  insufficiency  (Eich- 
horst,  Boas).  If  the  insufficiency  be  due  to  a  stenosis  of  the  duo- 
denum, the  stomach  may  very  well  be  distended  by  CO2  or  air,  in 
spite  of  insufficiency.  If,  after  finding  out  the  lower  limits  of  the 
stomach,  quantities  of  water  are  introduced  through  the  tube,  and  no 
dullness  appears  in  the  lower  parts,  while  gurgling  noises,  before 
lacking,  now  become  audible  in  the  intestine,  and  if  the  intestinal 
loops,  just  before  this,  gave  a  tympanitic  resonance,  and  after  the 
introduction  of  water  exhibit  a  muffled  sound,  insufficiency  is  to  be 
inferred.  It  has  been  claimed  that  after  the  introduction  of  one  grain 
of  salol  or  o.i  gr.  of  iodoform  with  the  test-breakfast,  salicyluric  acid 
can  be  shown  in  the  urine  after  taking  the  former,  and  iodin  in  the 
saliva  after  taking  iodoform,  much  sooner  than  with  continence  of  the 
pylorus,  as  these  chemicals  enter  more  quickly  into  the  intestine,  and 
on  account  of  the  neutralization  of  the  hydrochloric  acid  by  the  alka- 
line intestinal  juice,  they  are  immediately  converted  into  soluble 
compounds  which  may  be  absorbed.  I  have  explained  the  fallacy 
of  these  tests. 

Insufficiency  of  the  pylorus  may  be  recognized  by  the  author's 
method  of  intubating  the  duodenum  ("Archiv  f.  Verdauungskrank- 
heit.,"  Bd.  11,  S.  85),  and  by  the  spiral  revolving  sound  of  F.  Kuhn, 
of  Giessen,  and  of  F.  B.  Turck,  either  of  which  may  be  used  for  sound- 
ing the  pylorus.  This  operation  was  first  performed  by  the  author 
and  also  by  Dr.  F.  B.  Turck,  and  Kuhn's  claims  of  priority  of  sound- 


ATONY    OF    THE    STOMACH.  77 1 

ing  the  pylorus  are  unfounded  (Hemmeter,  "Die  Prioritat  d.  Pylorus- 
Sonderung,"  " Centralblatt  f.  innere  Medicin,"  1897,  No.  2)  Tlie 
interesting  observation  of  a  case  of  insufRciency,  reported  b)^  Schiitz, 
in  which  it  was  possible  to  distend  the  stomach  by  means  of  CO 2  but 
not  by  air,  so  that  by  the  increased  irritation  of  the  mucous  mem- 
brane  of  the  pylorus  by  the  carbonic  acid  gas  a  contraction  '"^  the 
annular  muscle  was  brought  about,  but  with  the  forcing  in  of  air  the 
stomach  did  not  become  distended,  points  to  the  fact  that  different 
degrees  of  insufficiency  occur.  If,  as  easily  happens  in  a  case  of  py- 
loric insufficiency,  some  of  the  contents  of  the  intestine  go  back  into 
the  stomach,  causing  dyspeptic  complaints  by  the  irritation  of  the 
mucous  membrane  and  neutralization  of  the  HCl,  this  can  be  recog- 
nized by  testing  for  bile. 

Therapeutics. — If  symptoms  of  irritation  of  the  intestine — 
namely,  diarrhea — are  absent,  only  dietetic  treatment  is  necessary. 
In  order  to  relieve  the  intestine  of  its  excessively  burdensome  task, 
we  must  prescribe  easily  digestible,  well-prepared  foods,  which  are 
to  be  carefully  masticated,  and  are  not  to  be  taken  too  hot  or  too  cold. 

If,  on  the  other  hand,  complaints  such  as  diarrhea  appear,  we  must 
attempt,  in  addition  to  the  treatment  of  the  causal  disease,  to  get  rid 
of  the  insufficiency  by  means  of  massage,  internal  and  external  gal- 
vanization and  faradization  applied  directly  to  the  pylorus  by  the  au- 
thor's method  (a  spiral  electrode  contained  within  a  rubber  tube,  and, 
after  introduction,  brought  into  contact  with  the  pylorus,  as  demon- 
strated by  X-rays),  douches,  and  eventually  also  by  giving  strychnin, 
gr.  ^^,  t.  i.  d.  If  flatulence  and  constipation  arise  on  account  of  sup- 
pression or  loss  of  hydrochloric  acid  secretion,  which,  as  is  well  known, 
has  a  stimulating  effect  upon  the  peristalsis  of  the  intestine,  and, 
further,  acts  as  an  antiseptic,  then  the  massage,  as  well  as  the  gal- 
vanization, is  to  be  applied  also  to  the  intestine,  and  dilute  HCl  should 
be  administered  in  doses  of  30  drops  largely  diluted  and  taken  after 
meals  through  a  tube  or  the  double  Aaron  capsules.  In  all  other 
indications  the  treatment  must  be  directed  to  the  cause. 


ATONY  OF  THE   STOMACH   (Myasthenia   Gastrica;   Mechanical 
Insufficiency  of  the  Stomach). 

In  the  consideration  of  dilation  of  the  stomach  we  have  fully  quoted 
the  classifications  of  Riegel,  Schreiber,  Boas,  Naunyn,  and  Rosen- 
bach.     By  simple  atony  we  mean  that  combination  of  symptoms  in 
51 


772  NEUROSES    OF   THE    STOMACH. 

which  there  exists  a  disproportion  between  the  peristaltic  work  the 
stomach  has  to  perform  and  its  real  expelling  muscular  force.  Ob- 
jectively, the  disease  makes  itself  known  by  the  fact  that  the  ingesta 
are  retained  in  the  stomach  beyond  the  normal  time,  but  although 
the  muscular  action  of  the  organ  is  weakened,  the  food  is  eventually 
expelled  into  the  duodenum.  By  this  it  is  distinguished  from  the 
mechanical  insufficiency  of  the  second  degree,  the  pronounced  dila- 
tion, in  which  the  food  is,  as  a  rule,  permanently  retained  in  the  stom- 
ach, and  only  exceptionally  reaches  the  bowels.  Every  relaxation  of 
the  muscular  wall  that  is  not  due  to  any  pyloric  or  other  mechanical 
obstruction  may  be  justly  designated  as  an  atony.  In  simple  atony 
the  stomach  is  not  considerably  enlarged  in  the  empty  state,  but  only 
becomes  so  with  increasing  burdening  of  the  ingesta,  but  in  atonic 
dilation  the  diseased  organ  remains  in  a  dilated  state  even  after  it  is 
empty,  (i)  This  disease  may  occur  as  a  typical,  primary,  idiopathic 
neurosis,  as  a  consequence  of  persistent  overloading  of  the  stomach 
with  indigestible  food,  particularly  with  liquids.  It  may  appear  very 
suddenly  as  a  transient  affection,  under  the  influence  of  violent  emo- 
tional disturbances, — fright,  anger,  grief,  etc., — occurring  in  this 
way  principally  in  neurasthenic  persons.  It  is  probable  that  gastric 
myasthenia  may  be  inherited,  and  may  be  transmitted  through 
several  generations.  It  is  generally  referred  to  as  the  so-called  "weak 
stomach  "  in  some  families.  The  abuse  of  alcoholic  liquors,  particu- 
larly of  beer,  and  even  of  coffee  and  soups,  has  been  assigned  as  a 
cause.  (2)  Myasthenia  occasionally  appears  as  a  reflex  neurosis 
evolved  from  other  diseased  organs — for  instance,  diseases  of  the 
liver,  bile  passages,  peritoneum,  intestines,  kidney,  and  sexual  appa- 
ratus. (3)  It  occurs  as  a  secondary  neurosis,  constituting  part  of  the 
symptoms  of  hysteria,  neurasthenia,  gastrospasm,  cardiospasm,  and 
pylorospasm.  It  has  been  observed  as  a  complication  of  gastro- 
ptosis,  nervous  dyspepsia,  ulcer,  and  chronic  gastritis.  There  are  a 
number  of  intestinal  affections  which  may  be  complicated  with,  or 
even  cause,  atony.  These  are  stenosis  in  the  inferior  horizontal  por- 
tion of  the  duodenum,  or  stenosis  of  the  jejunum,  enteroptosis, 
and  stenosis  of  the  colon ;  passive  congestions  and  enlargements  of 
the  liver  and  cholelithiasis  are  definitely  known  to  be  etiological 
factors.  Critically  speaking,  we  designate  only  such  cases  gastric 
atony  in  which  the  organ  retains  its  normal  size  when  it  is  empty.  As 
soon  as  the  stomach  remains  permanently  enlarged,  even  when  it  is 
empty,  it  is  more  logically  classed  with  the  motor  insufficiency  of  the 


ATONY   OF    the;    STOMACH.  773 

second  degree,  as  atonic  dilation.  As  we  have  seen  in  the  section 
referred  to,  Riegel  makes  a  separate  class  for  stenotic  dilation. 

The  final  cause  of  simple  atony,  or  myasthenia,  is  malnutrition, 
overstretching  of  the  muscles  and  motor  nerves  of  the  stomach,  or 
an  early  and  progressed  exhaustion  after  undue  and  improper  exer- 
tion. Occasionally  unknown  neurotrophic  influences  may  be  respon- 
sible for  the  origin  of  atony.  As  secretion  and  absorption  depend 
more  or  less  upon  energetic  contraction  of  the  gastric  muscularis, 
they  are  in  most  cases  interfered  with  in  the  absence  of  effective 
muscular  tonicity.  The  gastric  contents  do  not  diminish  in  quantity 
as  rapidly  as  they  should,  and  in  consequence  of  this  the  gastric  wall 
is  excessively  expanded  by  the  prolonged  weight  of  food.  If  fermen- 
tation of  the  ingesta  occurs  with  abundant  formation  of  gases,  the 
expansion  will  be  still  greater.  The  gaseous  distention  may  secon- 
darily produce  spasm  of  the  pylorus  and  cardia,  thus  adding  another 
etiological  factor  to  the  causation.  If  the  atony  is  very  far  ad- 
vanced and  has  persisted  for  a  long  time,  it  may  develop  into  an  irre- 
parable dilation,  particularly  if  dietetic  and  hygienic  regulations  are 
disregarded.  We  have  observed  a  number  of  cases  of  this  kind,  in 
which  permanent  dilation  was  developed  when  long-standing  gastric 
distress  was  left  unheeded.  Myasthenia — by  diagnostic  methods  for 
judging  the  motility — may  be  found  to  be  very  pronounced,  and  still 
remain  latent  and  unnoticed  even  by  the  patient  for  a  long  time. 

The  following  is  an  example  of  this  class  of  cases : 

Miss  S.,  aged  twenty-two,  a  well-built  and  apparently  healthy  girl,  moving 
in  the  .best  circles  of  social  life,  complains  of  only  one  symptoih,  that  is  a 
severe  headache,  occurring  two  or  three  times  of  every  week,  and  lasting  for 
twenty-four  hours.  On  being  questioned  about  her  stomach,  she  asserts  that 
her  digestion  is  good,  appetite  excellent,  and  bowels  regular.  She  eats  all 
kinds  of  food  apparently  without  distress.  On  passing  the  tube  in  the  morn- 
ing, on  an  empty  stomach,  200  c.c.  of  a  slightly  yellowish  mucous  liquid  were 
obtained  which  shows  free  HCl  by  Congo  paper.  The  next  day  she  was 
directed  to  take  the  double  test-meal.  One  hour  after  the  second  meal  the 
contents  were  drawn,  and  rice  and  egg  of  the  early  breakfast,  which  was  taken 
six  and  a  half  hours  before,  were  still  present  in  her  stomach,  together  with 
a  considerable  amount  of  mucus.  Total  acidity,  60;  free  HCl,  20.  Subse- 
quently the  same  state  of  affairs  was  found  after  other  test-meals.  Peristole 
by  author's  method  decidedly  impaired. 

The  striking  feature  of  this  case  is  that,  although  there  was  a  pro- 
nounced gastric  atony,  the  patient  was  not  at  all  conscious  of  it,  and 
regularly  expressed  surprise  when  she  recognized  food  in  the  lavage 
that  had  been  taken  eight  to  twelve  hours  before.     It  is  very  proba- 


774  NKUROSES   Oif   THB   STOMACH, 

ble  that  such  cases  as  this  one  would  develop  the  unmistakable  symp- 
toms of  myasthenia  in  a  very  short  time  if  left  untreated.  The  au- 
thor examined  loo  members  out  of  a  medical  class  of  140  students; 
of  these,  five  had  gastric  atony  and  were  unaware  of  it.  Superacidity 
and  supersecretion  may  cause  cardiospasm  and  pylorospasm,  and 
subsequently  gastric  atony,  by  the  irritation  of  the  muscular  struc- 
tures of  the  orifices.  But,  reversely,  gastric  atony  may  cause  super- 
acidity  and  supersecretion  by  the  fact  that  the  ingesta  are  retained 
in  the  stomach  for  an  unduly  long  period,  and  thereby  excite  the  gas- 
tric glands  to  stronger  functioning.  Stiller  and  Boas  assert  that 
gastric  atony  rarely  develops  into  permanent  gastric  dilation.  The 
subjective  symptoms  of  gastric  atony  are  very  similar  to  those  of 
gastritis  and  incipient  dilation.  The  patients  complain  of  pressure 
and  pain  in  the  head,  the  feeling  of  pressure  and  distention  in  the 
stomach,  a  premature  sensation  of  fullness  during  eating  by  which 
the  appetite  becomes  appeased  very  rapidly,  very  frequent  eructa- 
tion, and  persistent  constipation.  The  feeling  of  pressure  is  inti- 
mately associated  with  the  ingestion  of  food.  When  the  stomach 
is  empty,  the  patient  feels  quite  well.  The  headache  is  very  fre- 
quently observed,  together  with  the  so-called  stomach  vertigo.  We 
agree  with  Boas  that  this  so-called  gastric  vertigo  (Trousseau,  "Ga- 
zette des  Hopitaux,"  1862)  is  much  more  frequently  found  in  atony 
and  dilation  than  in  any  other  gastric  disease.  The  feeling  of  pres- 
sure and  distention  may  persist  as  long  as  there  is  food  in  the  stom- 
ach :  in  recent  cases,  about  one  hour ;  in  advanced  cases,  it  continues 
from  one  meal  to  the  other.  One  of  the  most  frequent  symptoms  is 
eructation  of  air,  which  generally  has  the  taste  of  the  food  that  has 
been  last  taken.  We  have  noticed  that  the  most  annoying  sensations 
of  pressure  in  the  advanced  cases  are  felt  after  breakfast,  at  a  time 
when  one  would  presume  that  they  should  be  absent,  since  the  stom- 
ach should  have  been  rested  during  the  night.  The  duration  of  the 
time  after  meals  during  which  the  eructations  continue  is  generally  a 
good  indication  of  the  extent  and  degree  of  the  myasthenia.  In 
some  cases,  however,  we  may  be  confronted  with  typical  neurotic 
regurgitation  and  eructation,  that  has  existed  before  the  atony  de- 
veloped, and  then  this  indication  is  invalid.  If  there  is  hyperacidity, 
the  atony  may  be  associated  with  attacks  of  vomiting,  and  pyrosis  is 
generally  present.  The  constipation  is  undoubtedly  an  expression  of 
the  general  atony  of  the  entire  gastro-intestinal  tract. 

Objective  Symptoms. — The  most  important  distinguishing  sign 


SYMPTOMS   OF   GASTRIC   ATONY.  775 

between  simple  atony  and  dilation  consists  in  the  fact  that  the  stom- 
ach, in  the  former,  should  be  empty  in  the  morning,  when  nothing 
has  been  taken  since  the  previous  supper ;  in  other  words,  the  jejune 
stomach  of  atony  contains  no  food  particles,  while  the  stomach  in  a 
state  of  dilation  does  contain  them.  The  splashing  sound  in  the 
epigastric  region  is  absent  in  the  morning  with  simple  atony,  but  it  is 
present  in  dilation.  The  size  and  location  of  the  stomach  vary 
physiologically.  A  myasthenic  stomach  yields  and  distends  with 
greater  readiness  when  it  is  filled  with  water  or  air  than  a  normal 
stomach.  Boas  asserts  that  even  an  atonic  stomach  may  react  more 
normally  to  the  distending  force  of  water  and  air  in  such  cases  in 
which  the  superimposed  layers  are  swelled  and  much  thickened  by 
inflammatory  infiltration.  The  methods  of  investigation  and  diag- 
nosis which  we  have  found  useful  are,  in  addition  to  inspection,  palpa- 
tion, percussion,  and  auscultation,  the  distention  of  the  stomach  by 
air  or  carbon  dioxid  gas,  the  Hemmeter  intragastric  stomach-shaped 
bag,  and  the  gastrodiaphane.  Very  frequently  the  contour  of  the 
greater  curvature  may  be  recognized  on  the  outside  of  the  abdomen. 
Palpation  may,  in  some  cases,  instruct  us  concerning  the  limits  of  the 
organ,  and  enable  us  to  separate  it  from  adjacent  organs.  The  so- 
called  splashing  sound  may  be  elicited  by  permitting  the  patient  to 
drink  a  glass  of  water,  and  then,  placing  the  palm  of  the  left  hand 
firmly  over  the  right  hypochondriac  region,  and  by  gently  tapping 
the  epigastrium  with  the  right  hand,  the  sound  is  generally  very  evi- 
dent if  atony  is  present.  In  most  cases  of  gastric  atony  a  splashing 
sound'can  be  heard  with  binaural  stethoscope  on  shaking  the  stomach 
from  the  outside.  Dehio  has  given  a  very  expedient  method  for 
judging  the  elasticity  of  the  gastric  walls  by  means  of  gradually  in- 
creasing quantities  of  water :  at  first  |  of  a  liter  is  taken,  and  the  loca- 
tion of  the  greater  curvature  determined;  then,  in  short  intervals, 
f  of  a  liter  is  taken  at  three  successive  periods,  and  after  each  ^  of  a 
liter  increment  the  further  descent  of  the  greater  curvature  is  deter- 
mined by  palpation  and  percussion,  and  the  niveau  of  the  water  in  the 
stomach  ascertained  by  holding  the  funnel  against  the  abdominal 
wall  and  observing  the  level  at  which  water  either  flows  into  or  out  of 
the  organ.  A  healthy  stomach  will  not  reach  the  line  of  the  umbili- 
cus under  these  conditions,  while  an  atonic  stomach  may  have  trans- 
gressed'far  beyond  it.  Auscultation  elicits  sounds  only  when  the 
stomach  contains  liquids  or  shortly  after  they  are  ingested.  It  is 
best  to  use  the  binaural  stethoscope  in  these  cases,  as  then  both  hands 


776  NEUROSES    OP   THE    STOMACH. 

are  free  to  palpate  and  move  the  stomach  to  obtain  the  percussion- 
sound.  Boas  holds  that  we  have  no  reliable  method  to  test  the  gas- 
tric elasticity  and  tonicity  (/.  c,  p.  76).  We  consider  that  our  method 
of  recording  the  gastric  peristalsis  on  the  kymograph,  as  described  in 
the  first  part  of  this  book,  is  also  an  excellent  method  for  investigating 
the  gastric  tonicity,  for,  as  our  stomach-shaped  intragastric  bag  on 
being  distended  gradually  fills  out  the  lumen  of  the  stomach  exactly, 
the  indications  of  pressure  which  are  obtained  on  the  kymograph  are 
reliable  representations  of  the  tonicity.  INIoreover,  we  have  experi- 
mented with  an  electrodiaphane  contained  within  our  stomach-bag, 
so  that  when  the  bag  was  distended  in  a  dark  room,  the  gradual  de- 
scent of  the  greater  curvature  could  verv^  plainly  be  seen.  By  refer- 
ence to  the  description  of  the  apparatus  on  pages  80  to  82,  it  will  be- 
come evident  that  we  can  easilv  determine  the  amount  of  air  or  water 
with  which  the  bag  is  distended  within  the  stomach;  so  with  this 
method,  which  in  a  modified  form  was  also  used  independently,  after 
our  first  publication,  by  Professor  Moritz,  of  Munich,  for  studying  the 
gastric  motility,  we  may  determine  also  the  elasticity  and  tonicity  of 
the  stomach. 

Perciission. — In  percussion  of  the  stomach  we  must  attempt  to 
define  its  four  limits— viz.,  the  upper,  lower,  right,  and  left  limits. 
The  lower  limit  may,  on  percussion,  be  confounded  with  the  trans- 
verse colon  if  the  latter  still  be  in  its  normal  position.  The  way  out 
of  this  difficulty  is  to  fill  the  transverse  colon  with  water,  which  gives 
a  dull  percussion-note  through  the  abdominal  wall,  while  the  stomach 
may  be  distended  with  air  or  gas,  giving  a  clear  tympanitic  sound. 
When  both  the  stomach  and  the  colon  are  filled  with  gas  or  with  solid 
material  simultaneously,  it  is  almost  impossible  to  distinguish  be- 
tween the  two  by  percussion.  It  is  best  to  evacuate  the  colon  and- 
fill  the  stomach  with  water,  or  vice  versa  to  evacuate  the  stomach 
and  fill  the  colon  with  water.  In  our  clinic  we  use  the  rubber  stom- 
ach-shaped intragastric  bag  methodically,  and  when  it  is  distended, 
there  is  no  difficulty  at  all  to  percuss  and  palpate  the  stomach.  The 
determination  of  the  upper  border  of  the  stomach  is,  in  our  experi- 
ence, no  easy  matter,  since  there  are  no  ver\^  striking  differences  in 
the  percussion-note  of  the  lower  edge  of  the  left  lung  and  the  highest 
portion  of  the  gastric  fundus  which  is  normally  covered  over  ante- 
riorly by  the  lung  in  inspiration.  The  upper  border  may  be  best 
determined  by  filling  the  stomach  with  water  and  then  percussing 
over  the  left  lung  along  the  parasternal  line  from  above  downward. 


PERCUSSION    IX    GASTRIC    ATONY.  777 

Pacanowski  ("Deutsch.  Arch.  f.  klin.  Medicin,"  Bd.  xl,  S.  342)  gives 
the  following  determinations  of  the  upper  limit  of  the  stomach :  In 
the  left  parasternal  line  it  is  at  the  lower  edge  of  the  fifth  rib  or  in  the 
fifth  intercostal  space.  In  the  left  mammillary  line  the  limit  is  in  the 
fifth  intercostal  space  extending  to  the  sixth  rib,  or  into  the  seventh 
rib.  In  the  anterior  left  axillary  line  the  upper  limit  is  at  the  lower 
edge  of  the  seventh  or  eighth  rib,  rarely  under  the  eighth  rib.  The 
determination  of  the  left  and  right  gastric  limits  seems  most  imprac- 
tical to  us,  and  not  of  diagnostic  value,  because  here  we  may  con- 
found the  percussion-notes  of  organs  superimposed  upon  the  stomach. 

In  our  experience  a  clear  conception  of  the  size  and  location  of 
a  normal  stomach  can  be  obtained  only  when  it  is  distended  bv 
gas,  air,  or  water.  Naturally,  this  can  not  be  done  if  there  is  sus- 
picion of  recent  ulcer  or  perigastritis.  In  such  cases  we  now  coat 
the  inside  of  the  stomach  with  bismuth  subnitrate  with  a  gastric 
powder-blower,  and  observe  the  size  of  the  organ  bv  means  of  the 
X  rays  and  skiagraph — the  rays  being  cut  off  by  the  bismuth.  The 
powder  can  readily  be  blown  in  through  an  ordinary  soft  stomach- 
tube.  We  have  already  spoken  of  the  value  of  the  electrodiaphane 
in  ascertaining  the  size  and  location  of  the  stomach,  and,  notwith- 
standing numerous  objections,  consider  the  method  practical. 

After  all,  the  most  convenient  method  of  determining  gastric 
atony,  and  that  which  is  available  for  every  practitioner,  is  bv 
means  of  the  double  test-meal  used  in  our  clinics.  (See  pp.  121  and 
122.)  According  to  Boas'  suggestion,  a  full  meal  is  preferabh"  given 
in  the  evening,  when  a  healthy  stomach  will  show  no  demonstrable 
signs  of  food  particles  the  next  morning.  It  should  not  be  forgotten, 
in  this  connection,  that  even  healthy  stomachs  may  contain  mucus, 
gastric  juice,  and  bile  in  the  morning  before  food  is  taken.  The 
chemical  analysis  of  the  stomach-contents  in  gastric  atony  yields  no 
results  useful  for  diagnosis,  because  the  state  of  the  secretion  varies 
considerably  according  to  the  degree  of  the  mechanical  insufficiency. 
In  the  primarv^  stages  of  gastric  atony  superacidity  is,  as  a  rule, 
present ;  at  other  times  the  secretions  may  be  normal,  and,  in  the 
latter  stage,  we  may  have  subacidity  or  even  achylia.  The  drawn 
stomach-contents  in  atony,  on  settling  in  a  glass  vessel,  do  not  show 
the  three  characteristic  layers  of  solid,  liquid,  and  froth  which  are 
usually  found  in  the  drawn  contents  of  the  dilated  stomach.  We 
have  never  observed  processes  of  fermentation  in  simple  atony. 
The  secretion  of  pepsin  and  rennin  is  generally  found  to  be  propor- 


778  NEUROSES   OF   THE   STOMACH. 

tionate  to  the  secretion  of  HCl.  Thirst  is  normal,  and  the  amount 
of  urine  passed  is  not  reduced.  Disturbances  in  nutrition  may 
gradually  develop  if  the  diet  is  inappropriate  or  if  the  patient  refuse 
to  eat  sufficiently  for  fear  of  causing  gastric  distress. 

The  course  of  gastric  atony  is  a  chronic  one,  and  the  symptoms 
are  subject  to  many  deviations.  Stiller  and  Boas  hold  that  gastric 
atony  comparatively  rarely  develops  into  dilation.  Notwithstand- 
ing this,  the  disease  generally  produces  considerable  systemic  weak- 
ness.    A  variety  of  nervous  disturbances  accompany  the  mala.dj. 

Prognosis. — In  recent  cases  the  prognosis  is  favorable,  provided 
that  they  are  systematically  treated  and  the  fundamental  causatives 
of  the  disease  can  be  removed;  but  in  pronounced  atony,  and  that 
of  long  standing,  complete  recovery  is  rare. 

Diagnosis. — Gastric  atony  and  myasthenia  may  be  confounded 
with  chronic  gastritis,  nervous  dyspepsia,  dilation,  and  megalogas- 
tria.  In  chronic  gastritis  the  stomach  is  not  enlarged,  as  a  rule, 
since  the  motility  is  good;  excess  of  mucus  is  common  in  gastritis 
and  rare  in  atony ;  but  as  atony  may  predispose  to  gastritis,  the  two 
affections  may  sometimes  exist  side  by  side.  Nervous  dyspepsia 
is  characterized  by  a  great  deviation  and  uncertainty  in  the  symp- 
toms; even  the  motility"  may  be  at  times  seemingly  much  affected, 
but  at  others,  if  the  case  be  strictly  watched,  the  motility  will  be 
found  to  be  perfect.  In  ner^'ous  dyspepsia  there  are  painful  points 
in  the  district  supplied  by  the  great  abdominal  sympathetic  plexuses 
— the  celiac,  solar,  and  h3^pogastric.  The  painful  spots  are  rare  in 
simple  atony.  Nervous  dyspepsia  and  aton}^  may  exist  simultane- 
ously, and  one  may  cause  the  other;  in  such  cases  it  will  be  difficult 
to  determine  which  is  the  primar>^  disease.  The  differential  diagnosis 
between  dilation  and  simple  atony  should  present  no  difficulties 
when  modern  methods  of  determining  the  size  and  capacity  and 
motility  of  the  stomach  are  used  (pp.  loi  to  1 14) ;  neither  should  there 
be  any  difficulty  in  distinguishing  atony  from  megalogastria,  since 
the  latter  is  not  a  disease,  but  simply  a  condition  of  big  stomach, 
which  performs  its  functions  normally. 

Treatment. — The  most  important  part  of  the  management  of 
gastric  atony  is  prophylaxis,  which  includes  the  avoidance  of  all 
known  causes  of  the  affection:  defective  teeth,  irregular  mode  of  life, 
hasty  eating,  and  abnormal  burdening  of  the  stomach  with  food  and 
drink,  constipation,  as  well  as  the  frequent  abuse  of  purgatives.  Even 
when  the  distinct  cause  of  the  malady  is  not  known,  one  will  do  best 


TREATMENT   OF   ATONY.  779 

to  prevent  the  full  development  of  myasthenia  b}'  rational  dietetic 
and  hygienic  treatment  before  functional  disturbances  become  mani- 
fest. We  have  already  remarked  that  atony  may  be  inherited. 
Whenever  this  is  noticed,  such  persons  should  be  particular^  guarded 
and  careful  in  the  selection  of  their  diet.  There  are  a  number  of  con- 
stitutional diseases  which,  in  our  experience,  undoubtedly  predispose 
to  this  state.  These  are  tuberculosis,  syphilis,  anemia,  chlorosis,  and 
cholelithiasis.  It  is  present  also  after  exhaustive  hemorrhages,  and 
is  particularly  ominous  when  the  condition  occurs  after  hemorrhages 
from  gastric  ulcer. 

Typhoid  fever  has,  in  our  experience,  frequently  been  followed  by 
gastric  atony ;  the  same  is  true  of  infectious  diseases  generally,  par- 
ticularly scarlet  fever,  malaria,  diphtheria,  and  influenza.  We  have 
also  noticed  gastric  atony  follow  a  number  of  operations  for  abdomi- 
nal tumors,  and  particularly  ovarian  neoplasms.  It  is  very  probable 
that  the  relaxation  of  the  gastric  walls  is  here  largely  due  to  mechani- 
cal causes,  similar  to  that  ^vhich  occurs  after  very  frequent  and  rap- 
idly consecutive  pregnancies.  In  all  of  these  instances  the  abdominal 
walls  do  not  regain  their  tonicity.  We  have  described  this  condi- 
tion fully  in  the  section  on  Gastroptosis.  Prophylaxis  consists  in 
appropriate  hygienic  living,  much  sleep  (at  least  nine  hours  in  the 
twenty -four),  and  strengthening  of  the  abdominal  muscles — the  latter 
is  one  of  the  most  important  elements,  not  only  in  prophylaxis,  but 
also  in  the  treatment  of  atony.  The  training  of  the  abdominal  mus- 
cles should  be  carried  out  according  to  rules  laid  dow^n  in  lllo way's 
work  on  "Constipation,"  and  Sandow's  book  on  physical  culture. 
The  treatment  proper  of  a  fully  developed  atony  must  have  regard  for 
the  fundamental  cause — for  instance,  in  syphilis  specific  treatment 
will  be  the  only  proper  course  to  pursue;  in  anemia  we  must  have 
recourse  to  preparations  of  iron  which  have  no  direct  deleterious 
effect  upon  the  mucosa.  Among  these  preparations  we  prefer  the 
iron  albuminates  and  peptonates,  also  ferratin  and  extract  of  bone- 
marrow.  With  pronounced  enteroptosis,  particularly  in  women, 
abdominal  gymnastics  can  not  be  effectively  carried  out,  on  account 
of  the  great  exhaustion  of  the  patient. 

In  some  cases  of  this  type  palliative  results  may  be  obtained  by 
abdominal  massage,  faradization  of  the  abdominal  muscles,  baths, 
and,  last  but  not  least,  a  well-fitting  abdominal  bandage.  In  a  few 
cases  it  will  not  be  possible  to  trace  any  cause  whatever,  though  even 
in  these  it  is  well  to  carefully  study  the  alimentar}'  tract  itself  before 


ySo  NEUROSES    OF    THE    STOMACH. 

giving  up  the  hope  of  determining  the  etiolog\\  The  most  important 
factors  of  direct  treatment  are:  (i)  diet,  (2)  hydriatic,  (3)  electric 
procedures,  (4)  massage,  and  (5)  medicines.  The  principle  under- 
lying the  diet  in  gastric  atony  is  that  of  frequent  and  vers'  small  meals, 
which,  although  quite  nutritious  and  digestible,  must  not  be  vol- 
uminous. The  diet  should,  as  a  rule,  consist  of  fats,  carbohydrates, 
and  proteids,  mixed.  If  there  is  an  excess  of  HCl,  there  is  no  objec- 
tion to  increasing  the  proteid  food,  but  in  doing  so  it  is  well  to  watch 
the  ratio  of  the  ethereal  to  the  combined  sulphates,  and  the  indican 
in  the  urine.  If  the  ratio  of  the  preformed  to  the  combined  sulphates 
is  vers^  high,  and  there  is  an  excess  of  indigo  in  the  urine,  it  is,  in  our 
experience,  worth  the  trial  of  adding  more  fats  and  artificially  pre- 
pared amylaceous  foods,  such  as  dextrinized  flours,  etc.,  for  it  has 
been  found  that  the  general  symptoms,  as  well  as  the  aforementioned 
indications  in  the  urine  (in  rare  instances,  in  which  proteid  diet  does 
not  agree  in  hyperacidity),  will  improve  if  the  proteids  are  cut 
down  and  the  other  food  substances  increased.  Together  with  this 
diet  in  hyperacidity  the  use  of  alkalies,  magnesia  usta,  sodium  bicar- 
bonate, etc.,  and  of  ptyalin,  or  of  malt  or  taka-diastase,  is  sometimes 
serviceable.     We  recommend  the  following  diet  for  gastric  atony : 

8  A.  M. — 250  gm.  of  bouillon,  oatmeal,  or  100  gm.  of  milk  and  100  gm.  of  tea 

or  coffee. 
10  A.  M. — One  soft-boiled  egg,  or  70  gm.  of  finely  scraped  tenderloin,  either 

raw  or  broiled,  and  20  gm.  of  toast. 
12  M. — A  broiled  sweetbread,  or  150  gm.   of  broiled  oysters,    or  little-neck 

clams,  or  100  gm.  of  finely  scraped  beef  slightly  fried  in  butter  ;  200  gm. 

of  potato  puree,  and,  if  hyperacidity  is  present,  we  give  half  a  wineglassful 

of  some  reliable  malt  extract. 
3  p.  M. — 200  gm.  of  Mosquera's  beef  chocolate  (P.,  D.  &  Co.). 
6.30  p.  M. — 60  gm.  of  scraped  raw  ham,  or^the  same  amount  of  fried  perch  or 

carp  ;   50  gm.  of  toast,  and  30  gm.  of  butter. 
10  P.  M. — 100  gm.  of  some  approved  light  Moselle  wine. 

This  list  calls  for  six  small  meals  in  the  day,  and  is  modeled  after 
those  recommended  in  European  text-books.  We  have  found  that 
very  frequently  the  atonic  stomach  is  unable  to  evacuate  one  meal 
before  another  is  taken.  This  danger  should  be  studiously  avoided, 
and  if  detected,  it  is  best  to  allow  only  two  meals  a  day — a  breakfast 
and  a  late  dinner — according  to  principles  laid  down  in  the  chapter 
on  the  Use  and  Abuse  of  Rest,  etc. 

In  the  section  on  Dietetics  we  have  given  other  diet-lists  suitable 
for  this  affection.     A  number  of  competent   authors  consider  the 


DIETETIC    MANAGEMENT   OF   ATONY.  78 1 

treatment  of  atony  and  a  chronic  dilation  together  in  the  same 
chapter.  Personally,  we  draw  a  very'  sharp  distinction  between 
these  two  affections  and  their  treatment.  The  therapy  of  dilation  is 
considered  in  the  chapter  devoted  to  this  subject. 

The  total  quantity  of  liquids  should  be  limited  to  i^  liters  a  dav. 
This  includes  the  soups,  coffee,  tea,  milk,  alcoholic  beverages,  and 
water.  Alcohol,  except  in  the  quantities  suggested  in  the  diet-list, 
should  not  be  allowed.  Purgatives  and  narcotics  are  forbidden.  If 
the  thirst  is  intense,  which,  however,  is  rarely  the  case,  water  may  be 
introduced  by  enema.  When  milk  is  well  digested,  and  no  idiosyn- 
crasy exists  against  it,  so-called  milk  cures  may  have  a  beneficial 
effect.  There  is  no  doubt  that  an  exclusive  milk  diet  insures  rest  and 
is  ver\'  sparing  upon  the  stomach,  but  it  is  a  two-edged  sword.  We 
have  seen  cases  in  which  the  atony  undeniably  became  aggravated 
by  the  milk  diet.  The  diet  must  van,-  also  with  the  amount  of  HCl 
secreted.  With  increased  secretion  of  HCl  the  meats  may  be  per- 
mitted to  prevail.  All  meats  should  be  run  through  the  meat-chop- 
per. Eggs  in  all  forms  are  permissible  in  this  state.  When  the  secre- 
tion of  HCl  is  diminished,  we  permit  the  use  of  spinach,  carrots,  beans, 
cauliflower,  and  asparagus.  All  vegetables  should  be  cooked  and 
given  in  the  form  of  purees ;  among  these  are  the  potato,  rice,  sago, 
pea,  and  bean  puree.  The  use  of  beer  should  be  forbidden  or  ven,' 
greatly  limited;  we  do  not,  as  a  rule,  forbid  small  doses  of  good  wine. 
Where  good  wine  can  not  be  obtained,  it  is  safest  not  to  prescribe 
wine  of  a  doubtful  quality,  but  to  order  dilute  whisky  or  brandy. 
Constipation  should  be  met  with  proper  diet,  and  medicines  should 
not  be  used  unless  they  are  positively  unavoidable.  We  have  al- 
ready spoken  of  the  diet  best  suited  for  constipation.  In  verv  stub- 
born and  protracted  cases  glycerin  suppositories  and  water  injections 
will  be  more  effective  than  medicines  given  by  the  mouth.  (See 
Illoway  on  "Constipation,"  and  E.  A.  Ewald,  "Ueber  d.  habituelle 
Obstipation  u.  ihre  Behandlung,"  1897.)  An  advantage  is  gained  by 
going  to  stool  at  a  definite  hour.  There  are  cases,  however,  in  which 
a  natural  stool  that  occurs  ever}'  two  or  even  every  three  days  spon- 
taneously is  much  better,  and  will  do  more  toward  gradual  recovery 
from  the  evil  of  constipation  than  a  stool  produced  artificially  even,- 
day.  Where  the  patient  insists  on  medicine,  and  it  is  really  un- 
avoidable, aloes,  strychnin,  and  cascara  sagrada  are  most  favored  by 
the  author.  (The  syrup  cascara,  "active,"  Clinton  Pharm.  Com- 
pany, and  the  elixir  and  fluid  extract  of  cascara  sagrada,  P.,  D.  &  Co., 


782  NEUROSES   OF   THE   STOMACH. 

or  S.  &  D.,  can  be  safely  recommended.)  Podophyllin  in  the  form  of 
pills  is  a  proper  medication.  The  following  formula  is  the  one  which 
we  favor: 

R.     Podophyllin,    .        0.26  gr.  iv 

Strychnin  sulphate, 0.2  gr.  y^, 

Glycyrrhizae, q.  s.  M. 

Ft.  pil.  No.  xii. 

SiG. — One  pill  before  supper  and  one  at  bedtime.     Dose  increased  to  two  pills 
the  next  day  if  necessary. 

The  compound  extract  of  rhubarb  is  also  an  effective  combina- 
tion; but  calomel,  colocynth,  jalap,  and  scammony,  and  the  very 
concentrated  purgative  waters,  such  as  the  Hunyadi  Janos,  the 
Rubinat-Condal,  and  Veronica'  must  be  avoided  if  possible.  Boas, 
in  contrast  to  other  authors,  states  that  lavage  is  not  only  unneces- 
sary, but  harmful  in  simple  atony,  because  stagnation  does  not 
occur  in  this  disease  and  there  is  therefore  no  necessity  for  washing 
out  the  stomach.  I  employ  lavage,  however,  not  to  combat  any  pre- 
sumable stagnation,  but  as  a  sort  of  intragastric  hydropathic  mas- 
sage. For  this  purpose  I  use  an  intragastric  douche  with  hot  and 
cold  water  alternating.  The  instrument  devised  by  F.  B.  Turck  is 
useful  for  this  purpose.  The  electrical  treatment  with  which  Binhorn 
has  achieved  remarkable  results  is  undeniably  a  valuable  means  of 
therapeusis  in  this  affection.  It  may  be  applied  externally  with 
large  felt-covered  plates  applied  to  the  abdomen  directly,  or  by  the 
intragastric  electrode.  We  usually  apply  the  current  fifteen  minutes 
and  repeat  it  daily  for  three  weeks.  Massage  should  be  applied, 
not  only  to  the  stomach,  but  to  the  entire  abdomen.  The  method 
of  application  (concerning  abdominal  massage,  see  Illoway  on  "Con- 
stipation"; Hoffa,  "Technik  d.  Massage,"  Stuttgart,  Enke,  1893; 
also  Penzoldt  and  Stintzing,  "Handbuch,"  Bd.  iv,  S.  34-39)  is 
described  on  pages  292-301. 

Treatment  by  Medicines. — The  only  drug  which  one  may  depend 
on  for  improving  the  gastric  tonicity  is  strychnin.  When  atony  is 
accompanied  with  suppression  of  gastric  juice  and  anacidit}",  we 
can  practically  associate  it  with  HCl  and  gentian  in  the  following 
manner : 

R.      Strychnin  sulphate, 0.02  gr.  ^ 

Dil.  hydrochloric  acid, 15.6  f^iv 

Elixir  of  gentian, q.  s.  180. o  f^^j.  M. 

SiG. — One-half  of  an  ounce  in  two  ounces  of  water,  after  meals,  through  a  glass 
tube,  three  times  a  day. 


LITERATURE   ON   GASTRIC   NEUROSES.  783 

When  there  is  excess  of  HCl,  it  is  well  to  combine  the  str^^chnin 
in  the  following  manner : 

R.      Strychnin  sulphate, 0.02  gr.  ^ 

Bismuth  salicylate,      .    - 7.5  gij 

Sodium  bicarbonate, 11.25  ^:^iij 

Magnes.  ustse, 4.0  ^j 

Peppermint  water  enough  to  make  ....  180.0  ^vj.  M. 

SiG. — A  tablespoonful  in  a  wineglassful  of  water  after  each  meal  t.  i.  d. 

Creasote  has  been  recommended  by  Klemperer  ("Berlin,  klin. 
Wochenschr.,"  1889,  No.  11)  and  A.  Pick  ("Vorl.  iiber  Magen-  u. 
Darmkrankh.,"  1895),  but  Fleischer  has  found  that  the  motility  is 
still  more  reduced  under  creasote,  and  in  the  author's  experience  it 
proved  useless.  Ergotin,  which  is  recommended  by  Leube,  is,  in 
my  opinion,  a  doubtful  remedy  for  this  purpose.  Ichthyol  has  been 
claimed  by  Pick  to  benefit  atony,  particularly  when  it  is  associated 
with  fermentative  processes  in  the  bowels.  In  severe  cases  of  gastric 
atony  with  recurrent  gastric  distress  we  have  had  very  gratifying 
results  by  rectal  feeding  for  from  six  to  eight  days,  and  total  exclusion 
of  food  from  the  stomach :  that  is,  we  treated  the  atony  as  we  would 
treat  a  severe  gastric  ulcer.  The  good  results  were  permanent. 
During  the  period  of  rectal  feeding  the  patient  must  remain  in  bed. 

LITERATURE  ON  NERVOUS  DISEASES  OF  THE  STOMACH. 

1.  Adler  and  Stern,  "  Berl.  klin.  Wochenschr.,"  1889,  Nr.  33. 

2.  Alt,  Konrad,  "  Ueber  das  Bestehen  von  Neurosen  und  Psychosen  auf 
dem  Boden  von  chronischen  Magenkrankheiten,"  "  Archiv  f.  Psychiatric  u. 
Nervenkrankheiten,"  Bd.  xxiv,  1892. 

3.  Alvermann,  "  Die  nervose  peristaltische  Unruhe  des  Magens  und 
Darms,"  Dissert.,  Bonn,  i895-'96. 

4.  Arany,  S.  A.,  "  Ueber  Dyspepsia  nervosa  und  was  als  solche  diagnosticirt 
wird,"  "  Ungar.  med.  Presse,"  1898,  iii,  706-711. 

5.  Bamberger,  "  Tetanic  bei  Magendilatation,"  Bericht  der  "Contracture 
Mortelle  d'Origine  Gastrique,"  "  Gaz.  Hebdoni.,"  1889. 

6.  Bentejac,  "These  de  Paris,"  1888. 

7.  Berlizheimer,  "  Ueber  einen  Fall  von  Magentetanie,"  "  Berl.  klin.  Woch- 
enschr.," 1897,  xxxiv,  773-775. 

8.  Biernacki,  "  Berl.  klin.  Wochenschr.,"  1891,  Nr.  25  u.  26. 

9.  Boas,  "  Ueber  periodische  Neurosen  des  Magens,"  "  Deutsche  med. 
Wochenschr.,"   1889. 

10.  Bourneville  et  Seglas,  "  Du  Merycisme,"  "  Arch,  de  Neurologie,"  Paris, 
1883. 

11.  Bouveret,  L.,  "  Traite  des  Maladies  del'Estomac,"  Paris,  1893,  p.  654. 

12.  Bouveret  et  Devic,  "  Recherches  Cliniques  et  Experimentales  sur  la 
Tetanie  d'Origine  Gastrique,"  "  Revue  de  Med.,"  1892,  xii. 


784  NEUROSEJS    OF    THE    STOMACH. 

13.  Brieger,   "  Deutsche  med.  Wochenschr.,"  1880,  Nr.  14. 

14.  Briigelmann,  W.,   "  Ueber  Hemicraniagastrica,"  "  Berl.  klin.  Wochen- 
schr.," 1883. 

15.  Buch,    "  Wirbelweh  eine  neue  Form  der  Gastralgie,"    "  Petersb.  med. 
Wochenschr.,"  1889. 

16.  Burkart,    "  Zur  Pathologic  der  Neurasthenia  gastrica,"  Bonn,  1892. 

17.  Cahn,  "  Deutsches  Archiv  f.  klin.  Med.,"  1884,  S.  402. 

18.  Cantarono,  G.,  "Neurolog.  Centralbl.,"  Bd.  iv,  1885. 

19.  Cartier,    "Action    de  la  Feinture   de   Sode  Centre   le  Vomissement," 
"  L'Union  Med.,"  1889. 

20.  Chantemesse  et  Le  Noir,  "  Nevralgies  Bilaterales  et  Dilatation  de  I'Es- 
tomac,"  "  Arch.  Gen.  de  Med.,"  1885. 

21.  Charcot,   "  Des  Crises  Gastriques  Tabetique  avec  Vomissements  Noirs," 
"  Gaz.  Med.  de  Paris,"  Sept.,  1892. 

22.  Charcot,  "  Lemons  sur  les  Maladies  du  Systeme  Nerveux,"  1886.. 

23.  Claus,   "  Hysterisch  onbedwing  baar  braken  hyprotherapie,"  "  Medisch. 
Weekblad,"  1896,  30,  v. 

24.  Cordes,     "  Die    Platzangst, — Symptom    einer     Erschopfungsneurose," 
"  Arch.  f.  Psych.,"  Bd.  in,  1872. 

25.  Cordes,  "  Einiges  iiber  Platzangst,"  "  Archiv  f.  Psych.,"  Bd.  x,  1880. 

26.  Debove,  "  Crises  Gastriques  non  Fabetiques,"  "  Bull,  de  la  Soc.  Med. 
des  Hop.,"  1889. 

27.  Dehio,  "  Singultus  als  Reflexneurose,"  "  Berl.  klin.  Wochenschr.,"  1889. 

28.  Delamarre,   "  Des  Crises  Gastriques  dans  I'Ataxie  Locomotrice,"  "These 
de  Paris,"  1866. 

29.  Demange,  "  Revue  de  Medecine,"  1892. 

30.  De  Sere,  L.,  "  Du  Relachement  du  Pylore,"  "  Gaz.  des  Hop.,"  1864,  No.  62. 

31.  Doyen,  "  Les  Spasmes  du  Pylore,  ses  Rapports  avec  I'Hyperstenie  Gas- 
trique,"  "  Med.  mod.,"  Paris,  1897,  viii. 

32.  Dubois,    "Crises   Gastriques   dans    I'Ataxie  Locomotrice,"  "These  de 
Paris,"  1888. 

33.  Ebstein,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xxvi,  S.  295. 

34.  Edinger,  "  Deutsches  Archiv  f.  klin.  Med.,"  1881. 

35.  Edlefsen,    "  Ueber  Husten    und  Magenhusten,"  "  Deutsches  Archiv  f. 
klin.  Med.,"  Bd.  xx. 

36.  Edwards,  L.  B.,   "  Gastralgia  :  Its  Forms,  Recognition,  and  Treatment," 
"Practice,"  Richmond,  1897,  xi,  62-74. 

37.  Einhorn,  Max,    "A  Case    of  Dysphagia  with  Dilation  of  the  Esopha- 
gus," "  Med.  Record,"  1888. 

38.  Einhorn,  "  Eine  neue  Methode  der  directen  Magenelektrisation,"  "Berl. 
klin.  Wochenschr.,"  1891. 

39.  Einhorn,  "  Weitere  Erfahrung    iiber  die  directe  Elektrisation  des  Ma- 
gens,"  "  Zeitschr.  f.  klin.  Med.,"  1893. 

40.  Erb,  "  Handbuch  der  Elektrotherapie,"  2.  Aufl.,  Leipzig,  1886. 

41.  Erb,  "Ueber  die  wachsende  Nervositat  unserer  Zeit,"  Prorectoratsrede, 
Heidelberg,  1893. 

42.  Ewald,  "  Neurasthenica  dyspeptica,"  "  Verhandlungen  des  Congresses 
fur  innere  Medicin,"  1884. 

43.  Ewald,    "  Enteroptose  und  Wanderniere,"  "  Berl.   klin.  Wochenschr.," 
1890. 


LITERATURE    ON   GASTRIC    NEUROSES.  785 

44.  Ewald,  "  Some  Forms  of  Gastralgia,"  "  Internat.  Clin.,"  Philadelphia, 
1898,  II. 

45.,  Fenwick,  "  Oa  Atrophy  of  the  Stomach  and  on  Nervous  Affections  of 
the  Digestive  Organs,"  London,  1880. 

46.  Fenwick,  "  Hyperacid  Dyspepsia,"  "  Med.  Press  and  Circ,"  London 
1897,  LXIV. 

47.  Fenwick,  "Paroxysmal  Hyperacidity  in  Children  Simulating  Migraine,' 
"  London  Lancet,"  January  8,  1898. 

48.  Fenwick,  "  Hyperesthesia  of  the  Mucous  Membranes  of  the  Stomach,' 
"  Med.  Press  and  Circ,"  London,  1898,  Lxv,  327. 

49.  Fenwick,  "  Ueber  spasmodische  Strictur  der  Cardiaoffnung  des  Magens,' 
"  Wien.  med.  Bl.,"  1898,  xxi,  327-344. 

50.  Ferrari,  E.,  "  Ectasia  e  tetania  gastrica,"  "  Practice,"  Firenzo,  i897-'98 
III. 

51.  Fleiner,  "  Ueber  die  Veriinderungen  des  Nervensystems  bei  Addison- 
scher  Krankheit,"  "  Zeitschr.  f.  Nervenheilk.,"  1892. 

52.  Fleiner,  "  Ueber  die  Behandlungen  einiger  Reizerscheinungen  und  Blut- 
ungen  des  Magens,"  "  Verhandlungen  des  XH.  Congresses  f.  innere  Medicin," 
Wiesbaden,  1893. 

53.  Fleiner,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
"  Sammlungkhn.  Vortrage,"  1894,  Nr.  103. 

54.  Fleiner,  "  Ueber  Neurosen  gastrischen  Ursprungs,  mit  besonderer 
Beriicksichtigung  der  Tetanie  und  ahnlicher  Krampfanfalle,"  "  Archiv  f.  Ver- 
dauungskrankh.,"  Bd.  i,  1895. 

55.  Flemming,  "Ueber  Pracordialangst,"  "  AUgem.  Zeitschr.  f.  Psychiatrie," 
Bd.  V,  1848. 

56.  Fothergill,  cf.  Krakauer,  "  Der  Chron.  Morb.  Brightii  der  atherom. 
Process  und  das  Blut  in  ihren  Wechselbeziehungen,"  Berlin  und  Neuwied, 
1892. 

57.  Frankl-Hochwart,  V.,   "  Die  Tetanie,"  Berlin,  1889. 

58.  Freund,  E.,  "  Ueber  Intoxications  erythyme,"  "Wien.  med.  Wochen- 
schr.,"  1894. 

59.  Fiirbringer, ,"  Ueber  Magenschwache,"  "  Deutsche  med.  Zeitung,"  1893. 

60.  Cans,   Edg.,  "  IX.  Congress  f.  innere  Medicin,"  Wiesbaden,  1890. 

61.  Garrigues,  "  Des  Dyspepsies  Hypoet  Hypersteniques,"  These  de  Mont- 
pelier,  1896. 

62.  Gassner,  "  Ueber  die  bei  Dilat.  ventric.  vorkommenden  tonischen 
Muskelkrampfe  und  epileptiformen  Anfalle,"  Inaug. -Dissert.,  Strassburg,  1868. 

63.  Geigel  und  Abend,  "  Die  Salzauresecretion  bei  Dyspepsia  nervosa," 
"  Virchow's  Archiv,"  Bd.  cxxx. 

64.  Gerhardt,  D.,  "  Zur  Lehre  von  der  Achylia  gastrica,"  "  Berl.  klin. 
Wochenschr.,"  1898,  xxxv,  765-768. 

65.  Glax,  G.,  "  Ueber  den  Zusammenhang  nervoser  Storungen'  mit  den 
Erkrankungen  der  Verdauungsorgane  "  und  "Ueber  nervose  Dyspepsie," 
"  Sammlung  klin.  Vortrage,"  1882,  Nr.  223. 

66.  Godart-Danhieux,  "La  gastralgie  nerveuse,"  "La  Policlinique,"  i,  11, 
1896. 

67.  Goldschmidt  E.,  "Ueber  den  Einfluss  der  Elektricitat  auf  den  gesunden 
und  kranken  menschlichen  Magen,"  "  Deutsches  Archiv  f.  klin.  Med.,"  1S95, 
Bd.  LVi. 


786  NEUROSES   OF  THE  STOMACH, 

68.  Gull,  "  Lancet,"  1868. 

69.  Gumprecht,  "  Magentetaine  und  Autointoxikation,"  "  Centralbl.  f.  innere 
Med.,"  Leipzig,  1897,  xviii,  569-593. 

70.  Hadra,  B.  E.,  "Neuroses'  of  the  Stomach  from  a  Surgical  Standpoint," 
"Texas  Med.  Jour.,"  Austin,  i8q7-'98,  xiii,  319-344. 

71.  Halipre,  "  Un  cas  de  Dyspepsie  Nervomotrice,"  "Normandie  Medicale," 
I,  VII,  1896. 

72.  Halliday,  A.,  "  The  Condition  of  the  Gastric  Secretion  in  Merycism," 
"  Med.  Record,"  New  York,  1897,  Lii. 

73.  Hamilton,  H.  J.,   "  Hyperchlorhydria,"  "  Canad.  Pract.,"  Toronto,  1897, 
XXII. 

74.  Havel,  "  Des  Crises  Gastriques  dans  I'Ataxie  Locomotrice,"  "These  de 
Paris,"  1882. 

75.  Hayem,  "Bull.  Medicale,"  1891,  No.  87. 

76.  Hayem,  "  Sur  Un  cas  de  Chloro-dyspepsie  avec  Neurasthenie,"  "Med. 
Mod.,"  20  Janvier,  1897. 

']'].  Hayem,  "  De  I'Hyperchlorhydrie    par  Saturation  Alcaline,"  Soc.  Med. 
du  Hop.,  15  Avril,  1898. 

78.  Hayem,  "  Sur  la  Gastralgie,"  "  Rev.  Gen.  de  Clin,  et  de  Therap.,"  Paris, 
1898,  XII,  353-357- 

79.  Henoch,    "  Ueber  Asthma  dyspepticum,"  "  Berl.  klin.  Wochenschr.," 
1876,  Nr.  18. 

80.  Herz,  M.,  "  Fall  von  motorischer  Magenneurose,"  "  Wien.  klin.  Wochen- 
schr.," 1897,  X,  S.  1041. 

81.  Hildebrandt,  W.,    "  Nervose  Storungen  im  Gefolge  von  Magenkrank- 
heiten." 

82.  Hoffmann,  A.,   "  Ueber  den  Einfluss  des  galvanischen  Stromes  auf  die 
Magensaftabscheidung,"  "  Berl.  klin  Wochenschr.,"  1890. 

83.  Hoffmann,  J.,    "  Zur  Lehre  von  der  Tetanie,"  "  Heidelberger  Habilita- 
tionsschrift,"  1888. 

84.  Honigmann    G.,    "Ueber    die   Neurosen    des  Magens,"    "  Zeitschr.    f. 
prakt.  Aerzte,"  1897,  iv,  pp.  833-857. 

85.  Hubbard,  W.  A.,  "  Medical  Record,"  July  31,  1886,  p.  122. 

86.  Huefler,  "  Miinch.  med.  Wochenschr.,"  1889,  Nr.  33. 

87.  Hunt,  B.,    "On  Nervous  Vomiting,"  "Clin.  Jour.,"  London,  1898,  xii, 
pp. 238-240. 

88.  Hyde,  "Twentieth  Century  Practice  of  Medicine,"  vol.  v,  p.  170. 

89.  Immermann,    "  Verhandlungen    des  Congresses  fiir  innere  Medizin," 
Wiesbaden,  1889. 

90.  Jacobi,  A.,  "  Transactions  of  Association  of  American  Physicians,"  1894. 

91.  Jacobson  and  Ewald,  "  Ueber  Tetanie,"  "  Verhandlungen  des  Congresses 
fiir  innere  Medizin,"  1893. 

92.  v.  Jaksch,  "  Epilepsia  acetonica,"  "  Zeitschr.  f.  klin.  Med.,"  Bd.  x. 

93.  Johannessen,  "  Zeitschr.  f.  klin.  Med.,"  Bd.  x,  S.  274. 

94.  Jones,  Allen  A.,  "Gastric  Conditions  in  Renal  Disease,"  "  N.  Y.  Med. 
Jour.,"  Jan.  19,  1895. 

95.  Joslin,  E.  P.,  "  Hyperacidity  of  the  Stomach  and  its  Treatment,"  "  Bos- 
ton Med.  and  Surg.  Jour.,"  1898,  cxxxviil,  pp.  389-392. 

96.  Jiirgensen,  "Ueber  Abscheidung  neuer  Formen  nervoser  Magenkrank- 
heiten,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  XLIII. 


IvlTERATURE   ON   GASTRIC   NEUROSES.  787 

97.  Jurgensen,  C,  "  Ueber  die  Diat  bei  der  Superaciditat :  eine  kritische 
Litteraturstudie,"  "  Archiv  f.  Verdauungskrankh.,"  Berlin,  1897,  ill. 

98.  Kahler,  "  Prager  Zeitschr.  f.  Heilkunde,"  Bd.  11. 

99.  Kaufmann,  J.,  "  Zwei  Falle  geheilter  pernicioser  Anamie,  nebst  Bemer- 
kungen  zur  Diagnose  und  Therapie  dieser  Krankheit,"  "  Berl.  klin.  Wochen- 
schr.,"  1890,  Nr.  10. 

100.  Klemperer,  "  Berl.  klin.  Wochenschr.,"  1899,  Nr.  11. 
loi,  Koerner,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  x,  S.  274. 

102.  Koziczkowsky,  E.  von,  "  Beitrag  zur  Aetiologie  der  Magenneurosen," 
"Berl.  klin.  Wochenschr.,"  Nr.  7,  1897. 

103.  Kussmaul,  "Ueber  die  Behandlung  der  Magenerweiterung  durch  die 
Magenpumpe,"   "  Deutsches  Archiv  f.  klin.  Med.,"  1869,  Bd.  vi. 

104.  Kussmaul,  "  Die  peristaltische  Unruhe  des  Magens,"  "  Sammlungklin. 
Vortrage,"  1880,  Nr.  181. 

105.  Kutneff,  "Neurasthenic,  Herabsinken  von  Bauchorganen  und  gastro- 
intestinale  Atonie,"  Ref.  in  the  "  Jahresberichte,"  1894,  Bd.  11. 

106.  Laffite,  "Des  Crises  Gastriques,"  "Gaz.  des  Hop.,"  Jan.,  189^. 

107.  Landouzy  et  Dejerine,  Societe  de  Biologic,  1884. 

108.  Leo,  "  Ueber  Bulimie,"  "  Deutsche  med.  Wochenschr.,"  1889,  Nr.  29  u. 

3°- 

109.  Leube,  "  Ueber  nervose  Dyspepsie,"  "  Deutsches  Archiv  f.  klin.  Med.," 

1878,  Bd.  xxiii. 

no.  Leven,  "  Estomac  et  Cerveau,"  Paris,  1884. 

111.  Leven,  "  Phenomenes  Nerveux  lies  a  la  Dyspepsie,"  "  Gaz.  des  Hop.," 
1880,  No.  40. 

112.  Leven,  "  Phenomenes  Nerveux  qui  se  Produisent  sous  I'lnfluence  de  la 
Dyspepsie,"  ibid.,  1880,  No.  137. 

113.  Leyden,  "Ueber  Anfalle  von  periodischem  Erkrechen,  nebst  Bemer- 
kungen  iiber  nervose  Magenaffectionen,"  "  Zeitschr.  f.  klin,  Med.,"  Bd.  iv, 
1882. 

114.  Liebmann,  G.,  "  Meine  Erfahrungen  mit  Hyperacidilat,"  "  New  Yorker 
med.  Monatsschr.,"  1897,  ix,  311-318. 

115.  Liell,  E.  W.,  "The  Relation  of  the  Pregnant  Uterus  to  the  Reflex 
Nausea  and  Vomiung  Accompanying  Gestation,"  "  Amer.  Medico-Surg.  Bull.," 
21,  XI,  1897. 

116.  Littig,  L.  W.,  "Gastric  Neuroses,"  Transactions  Iowa  Medical  Society, 
Burlington,  1898. 

117.  Loeb,  M.,  "  Tetanie  bei  Magenerweiterung,"  "  Deutches  .Archiv  f. 
klin.  Med.,"  1890,  Bd.  lxvi. 

118.  Luzzato,  A.  M.,  "  Un  caso  di  mericissmo  connotevoli  alterazioni  del 
chimism.o  gastrico,"  "  Riv.  Ven.  di  Scienze  Med.,"  iii,  p.  116. 

119.  Lyman,  H.  M.,  "Nervous  Dyspepsia,"  "Jour.  Amer.  Med.  Assoc," 
1897,  xxviii,  pp.  959-962. 

120.  Malbranc,  "Ueber  Behandlung  von  Gastralgieen  mit  der  inneren 
Magendusche,"  etc.,  "  Berl.  klin.  Wochenschr.,"  1878. 

121.  Marcus,  A.,  "  Ein  Fall  von  hysterischer  Magenneurose  (unstillbares 
Erbrechen)  compliciert  mit  Diabetes  insipidus  bei  einem  Manne,"  Dissert., 
Miinchen,  i896-'97. 

122.  Mariani,  "  De  I'Hypersecretion  Gastrique,"  These  de  Montpellier, 
1896. 

52 


788  NEUROSES    OP   THE    STOMACH. 

123.  Mathieu  et  Milan,  "  Etude  sur  le  Pituite  Hemorragique  des  Hyster- 
iques,"  Paris,  1896. 

124.  Maybaum,  J.,  "Archiv  f.  Verdauungskrankh.,"  Bd.  i,  Heft  4. 

125.  Melzer,  S.  J.,  "  Berl,  klin.  Wochenschr.,"  1888,  No.  8. 

126.  Mitchell,  Weir,  "  Fat  and  Blood,"  Philadelphia,  1884. 

127.  Mobius,  S.  A.,  "  Ueber  dieschmerzstillende  Wirkung  der  Elektricitat," 
"  Berl.  klin.  Wochenschr.,"  1880. 

128.  Mongour  et  Lafarelle,  "  Spasme  du  Pylore,"  "Jour,  de  Med.de  Bor- 
deaux," 1898,  XXVIII,  p.  176. 

129.  Miiller,  Fr.,  "  Tetanie  bei  Dilatatio  ventriculi  und  Achsendrehung  des 
Magens,"  "  Charite  Annalen,"  1888,  Bd.  xiii. 

130.  Murdoch,  F.  H.,  "  The  Absence  of  Hydrochloric  Acid  in  the  Stomach, 
with  Report  of  Cases,"  "  Phila.  Med.  Jour.,"  1898,  i. 

131.  Murdoch,  F.  H.,  "  Nervous  Dyspepsia,  with  Report  of  Cases,"  "  N.  Y. 
Med.  Jour.,"  1898,  Lxviii,  pp.  437-439. 

132.  Muret,  "  Hyperemesis  gravidar.  und  Hysteric,"  "  Deutsche  med. 
Wochenschr.,"  1893. 

133.  Naunyn,  "  Zur  Lehre  vom  Husten,"  "  Deutsches  Archiv  f.  klin.  Med.," 

XXIII. 

134.  Neumann,  "  Deutsche  Klinik,"  1861,  Nr.  3. 

135.  Nonne,  "  Beitrage  zur  Kenntniss  der  im  Verlaufe  der  perniciosen  An- 
amie  beobachteten  Spinalerkrankungen,"  "Archiv  f.  Psychiatrie,"  Sep.  H., 
Bd.  XXV. 

136.  V.  Noorden,  "  Klinische  Untersuchungen  iiber  die  Magenverdauung  bei 
Geisteskrankheiten,"  "Archiv  f.  Psychiatrie  und  Nervenkrankheiten,"  Bd.  X. 

137.  V.  Noorden,  "  Pathologie  der  gastrischen  Crisen,"  "  Charite  Annalen," 
1890. 

138.  Oettinger,  W.,  "  Idiopathic  Gastric  Crises;  Periodical  Vomiting  of. von 
Leyden,"  "Med.  Weekly,"  1897,  v,  pp.  374-376. 

139.  Olivetti,  B.,  ed.  Muggia,  A.,  "  Azione  della  pilocarpina  suUa  secrezione 
chlorata  del  ventricolo  nell  ipoedana-chloridria,"  "  Gazz.  med.  di  Torino," 
1897,  XLVIII,  661-666. 

140.  Olivetti,  B.,  "  Fleiner's  Methode  in  der  Behandlung  der  Hyperchlor- 
hydrie,"  "  Therapeutische  Monatshefte,"  Berlin,  1898,  xii. 

141.  Oppenheim,  "  Berl.  klin.  Wochenschr.,"  1885. 

142.  Oser,  "  Die  Neurosen  des  Magens  und  ihre  Behandlung,"  "  Wiener 
Klinik,"  1885,  Heft  5  u.  6. 

143.  Pacanowski,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  XL. 

144.  Panecki,  "  Retroflexio  uteri  und  Magenneurose,"  "Therapeutische 
Monatshefte,"  1892. 

145.  Petitjean,  "Contribution  a  I'Etude  des  Crises  Gastriques  dans  I'Ataxie 
Locomotrice,"  These  de  Paris,  1874. 

146.  Pettyjohn,  E.  S.,  "  Functional  Gastric  Diseases  and  their  Treatment," 
"Physician  and  Surgeon,"  Detroit  and  Ann  Arbor,  1897,  Xix,  pp.  258-262. 

147.  Peyer,  A.,  "  Beitrag  zur  Kenntniss  der  Neurosen  des  Magens  und  des 
Darms,"  "  Correspondenzblatt  f.  Schweizer  Aerzte,"  1888. 

148.  Pick,  A.,  "  Ueber  Hyperasthesie  des  Magens,"  "  Wiener  med.  Wochen- 
schr.," 1898,  XLVIII. 

149.  Pidoux,  "  Rapport  de  I'Herpetisme  et  des  Dyspepsies,"  "  L'Union 
Med.,"  1866,  p.  235. 


LITERATURE    ON    GASTRIC    NEUROSES.  789 

150.  Ponsgen,  "  Diemotorischen  Verrichtungen  des  menschlichen  Magens," 
Strassburg,  1882,  S.  127. 

151.  Potain,  "  Paralysie  Consecutive  a  des  Troubles  Digestifs,"  "  Gaz.  des 
Hop.,"  1880. 

152.  Raymond,  "  Des  Dyspepsies,"  These  d'aggreg.,  1878. 

153.  Reed,  B.,  "The  Excessive  Secretion  of  Hydrochloric  Acid  by  the 
Stomach,  and  its  Possible  Serious  Consequences,"  "  Internal.  Clin.,"  1897. 

154.  Reed,  B.,  "A  New  Intragastric  Electrode  for  the  Treatment  of  Gas- 
tralgia  and  Deficient  Gastric  Motility  with  or  without  Dilation,"  "  Phila. 
Med.  Jour.,"  1898,  i. 

155.  Remond  (de  Metz),  "  Des  Crises  Gastriques  Essentielles,"  "Arch.  Gen. 
de  Med.,"  1889,  tome  11. 

156.  Renvers,  "  Berl.  klin.  Wochenschr.,"  1888,  Nr.  53. 

157.  Richet,  Ch.,  "  Du  Sue.  Gastrique  chez  I'Hommeet  lesAnimaux,"  Paris, 
1878. 

158.  Richter,  "  Ueber  nervose  Dyspepsie  und  nervose  Enteropathie,"  "  Berl. 
klin.  Wochenschr.,"  1882. 

159.  Riegel,  F.,  "  Zur  Lehre  von  der  Tetanie,"  "  Deutsches  Archiv  f.  klin. 
Med.,"  1873,  Bd.  xii. 

160.  Riesman,  D.,  "  Stomach  from  a  Case  of  Rumination,"  "  Tr.  Path. 
Soc,"  Philadelphia,  1898,  xviii,  p.  120. 

161.  Robin,  A.,  "  Gastro-succhoree  et  Stenose  Pylorique,"  "  Courier  med.," 
Paris,  1897,  XLVii,  p.  169. 

162.  Rockwell,  A.  D.,  "Atonic  or  Nervous  Dyspepsia  and  its  Treatment  by 
Intragastric  Electrization,"  "Internal.  Clin.,"  1898. 

163.  Rosenberg,  O.,  "  Beitrag  zur  Lehre  von  den  Krankheiten  des  Verdau- 
ungsapparates,"  "  Deutsche  med.  Wochenschr.,"  1879  (Vagusneurose). 

164.  Rosenbach,  O.,  "  Die  Emotionsdyspepsie,"  "  Berl.  klin.  Wochen- 
schr.," 1897. 

165.  Rosenheim,  Th.,  "  Berl.  klin.  Wochenschr.,"  1890. 

166.  Rosenheim,  Th.,  "  Ueber  nervose  Dyspepsie,"  "  Berl.  klin.  Wochen- 
schr.," 1897,  Nr.  34. 

i~67.  Rosenstein,  "  Berl.  klin.  Wochenschr.,"  1890,  Nr.  13. 

168.  Rosenthal,  "  Magenneurosen  und  Magenkatarrh,"  Wien  und  Leipzig 
1886. 

169.  Rossbach,  "  Nervose  Gastroxynsis  als  eine  eigene  characterisirbare 
Form  der  nervosen  Dyspepsie,"  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd.  xxiv. 

170.  Sansom,  A.  E.,  "A  Note  on  Neuropathic  Dyspepsia  and  its  Correlations 
with  Disturbances  of  the  Rhythm  of  the  Heart,"  "  Lancet,"  London,  1897,  11. 

171.  Sansom,  L.,  "  Sulla  pathogenesi  dell  iperchloridria  primitiva,"  "  Ref- 
orma  med.  Napoli,"  1897,  xiii. 

172.  Schetty,  F.,  "  Deutsches  Archiv  f.  klin.  Med,,"  Bd.  xliv,  S.  219. 

173.  Schnitzler,  J.,  "  Ueber  einen  Krampftumor  des  Magens,  nebst  Bemer- 
kungen  zum  sog.  Spasmus  pylori,"  "  Wiener  med.  Wochenschr.,"  1898,  XLVill. 

174.  Schuchardt,  "  Epileptiforme  Anfalle  bei  Magenerkrankungen,"  "All- 
gem.  Zeitschr.  f.  Psychiatrie,"  1882,  Bd.  xxxviii. 

175.  Schuie,  A.,  "  Einige  Bemerkungen  iiber  die  Hyperaciditat ;  die  Diat 
bei  derselben,"  "Archiv  f.  Verdauungskrankh.,"  1897,  Heft  in. 

176.  Schutz,  "Prager  med.  Wochenschr.,"  1882,  Nr.  11. 

177.  See,  G.,  "Anwendung   der  Cannabis  indica  in  der   Behandlung  der 


790  NEUROSKS    OF    THE    STOMACH. 

Neurosen   und   gastrischen    Dyspepsien,"    "  Deutsche   med.   Wochenschr.," 
1890. 

178.  Singer,  "  Die  Rumination  beim  Menschen  und  ihre  Beziehung  zum 
Brechact,"  "  Deutsches  Archiv  f.  klin.  Med.,"  1893,  Bd.  li. 

179.  Sinkler,  W.,  "  Rumination  in  Man,"  "  Jour.  Amer.  Med.  Assoc,"  April 
9,  1898. 

180.  Smith,    D.  E.,  "  Hyperchlorhydria,"   "  Northwest    Lancet,"   St.  Paul, 

XVII. 

181.  V.  Sohlern,  "  Zur  Behandlung  der  nervosen  Magenkrankheiten," 
"  Berl.  klin.  Wochenschr.,"  1891. 

182.  SoUier,  "Revue  de  Medecine,"  Aout,  189T. 

183.  Somers,  L.  S.,  "Merycisni,"  "Medical  Record,"  17,  iv,  1897. 

184.  Sorens,  O.,  und  Metzger,  L.,  "  Ueber  die  Diat  bei  Superaciditat," 
"  Miinch.  med.  Wochenschr.,"  1898,  XLV. 

185.  Stiller,  "  Die  nervosen  Magenkrankheiten,"  Stuttgart,  1884. 

186.  Stockton,  "  Medical  Record,"  1894. 

187.  Strauss,  "Des  Ecchymoses  Fabetiques  a  la  Suite  des  Crises  Doulour- 
euses,"  "Arch,  de  Neur.,"  1880-81. 

188.  Strauss,  "  Ueber  das  Vorkommen  von  Ammoniak  im  Mageninhalt," 
etc.,  "  Berl.  klin.  Wochenschr.,"  1893. 

189.  Talma,  "  Zur  Kenntniss  des  Leidens  der  Bauchsympathicus," 
"Deutsches  Archiv  f.  klin.  Med.,"  1892,  Bd.  XLix  ;  "  Zeitschr.  f.  klin.  Med.," 
1884,  Bd.  VIII,  S.  407. 

190.  Tere,  "  Note  pour  Servis  a  I'Histoire  des  Troubles  Gastrique  de  I'Epi- 
lepsie  et  de  I'Heredite  Morbide  Progressive,"  "Journal  de  Neurologie,"  5,  iii, 
1896. 

191.  Tournier,  C,  "  Ouelques  cas  de  Vomissements  Nevrosques,"  "Province 
Med.,"  Lyon,  1897,  xi. 

192.  Trousseau,  "  Med.  Klinik  des  Hotel  Dieu  "  in  Paris,  Bd.  iii,  1868,  Cap. 

193.  Upshur,  J.  N.,  "  Gastralgia,  with  Report  of  a  Case,"  "Medical  Reg- 
ister," Richmond,  1897,  i,  31. 

194.  Wagner,  G.,  "  Zur  Behandlung  der  Superaciditat  des  Magens  mit 
Bergmann'schen  Magenkautabletten,"   "  Therap.  Monatshefte,"  Berlin,  1897, 

XI. 

195.  Westfallen,  "  Kopfschmerzen  gastrischen  Ursprungs,"  "  Berl.  klin. 
Wochenschr.,"   1891. 

196.  Westphal,  C,  "  Ueber  Agarophobie,  eine  neuropathische  Erscheinung," 
"Archiv  f.  Psychiatrie,"  1872.  Bd.  iii. 

197.  Whitney,  H.  B.,  "Cyclic  Vomiting:  A  Brief  Review  of  this  Affection 
as  Illustrated  by  a  Typical  Case,"  "Arch.  Pediat.,"  1898,  xv. 

198.  Hemmeter,  J.  C,  "  Experimental  Basis  of  the  Treatment  of  Hyper- 
acidity," etc.,  "Journ.  Am,  Med.  Assoc,"  Oct.  9,  1897. 

199.  Hemmeter,  J.  C,  "  Histologic  d.  Magendriisen  bei  Hyperaciditat," 
"Archiv  f.  Verdauungskrankh.,"   Bd.  IV,  98,  S.  23. 


SENSORY  NEUROSES.  -791 


CHAPTER  XL 
SENSORY  NEUROSES. 

HYPERESTHESIA. 
Hyperesthesia  depends  upon  a  morbid  increase  in  the  irritabihty 
of  the  sensory  nerves  of  the  stomach.  It  is  probably  a  neurosis 
of  the  vagus,  and  a  mild  form  of  gastralgia.  Clinically,  the  two 
forms  of  gastric  sensibility — viz.,  gastralgia  and  hyperesthesia — 
are  differentiated  by  the  following  facts:  The  unpleasant  sensation 
of  pressure,  fullness,  and  pain  in  the  epigastrium,  with  eructations, 
nausea,  and  vomiting,  occur  in  hyperesthesia  only  after  the  ingestion 
of  food :  that  is,  there  must  be  a  digestive  stimulation  of  the  mucosa. 
The  distress  occurs  only  after  meals,  very  rarely  with  an  empty 
stomach;  but  in  gastralgia  the  pains  and  other  distress  occur  with 
equal  intensity  in  the  full  as  well  as  in  the  empty  stomach ;  digestive 
irritation  is  not  necessary  to  cause  gastralgia.  Hyperesthesia  lasts 
several  days,  weeks,  or  even  months,  with  uniform  or  gradually 
increasing  intensity,  and  during  this  time  dyspeptic  symptoms  occur 
dail)^  after  every  meal ;  in  gastralgia,  however,  the  pains  last  during 
the  attacks,  generally  for  a  few  hours  only.  In  the  intervals  between 
the  attacks  the  excitability  of  the  nerves  is  so  completely  arrested 
that  even  strong  irritation — like  the  overloading  of  the  stomach  with 
food — does  not  cause  a  return  of  the  pain.  The  various  acts  con- 
stituting normal  digestion,  the  movements  of  the  gastric  wall  and  of 
the  contents  of  the  digestive  tract,  are  phenomena  of  which  a  healthy 
person  is  not  conscious,  but  they  may  be  perceived  b}-  patients  with 
increased  sensitiveness  of  the  gastric  nerve-endings.  As  a  result  of 
this  nerA^ous  state  sensations  reach  consciousness  from  these  localities 
which  in  the  normal  being  would  not  pass  the  threshold  of  con- 
sciousness. The  disturbance  of  the  ner\"es  need  not  necessarily  be  in 
the  end  distributions  of  the  stomach ;  they  may  be  in  the  ner\-e  itself 
or  in  the  central  organ.  Most  frequently  the  seat  ma}^  be  in  the  per- 
ipheral nervous  end  organs  in  the  stomach ;  these  are  the  cases  that 
have  been  caused  by  improper  mode  of  life  and  various  insults  to 
the  mucosa.  In  other  rare  cases  the  gastric  hyperesthesia  may  be 
a  perception  due  to  increased  excitability  of  the  nervous  centers. 
In  order  to  intelligently  appreciate  the  sufferings  of  patients  with 


792  SENSORY  NEUROSES, 

increased  sensibility  it  is  necessary'  to  bear  in  mind  that  the  increased 
irritability  brings  about  the  perception  of  transactions  into  the 
digestive  tract  which  in  themselves  are  not  pathological,  and  if 
present  to  the  same  degree  in  a  healthy  individual,  would  not  be 
perceived.  The  natural  process  of  digestion  and  absorption  in  such 
patients  is  a  train  of  uninterrupted  distressing  sensations.  The 
patients  themselves  generally  misinterpret  their  condition  or  ex- 
aggerate it,  and  as  a  consequence  of  the  various  impressions  that  they 
perceive,  assume  that  they  suffer  from  severe  organic  disease.  They 
often  become  hypochondriacal.  H3^peresthesia  may  be  an  inde- 
pendent, idiopathic  or  secondary',  symptomatic  neurosis. 

Causation. — The  primar}^  idiopathic  form  occurs  vers'  frequently 
as  an  accompaniment  to  chlorosis  and  anemia,  particularly  with 
women  and  young  girls.  Also  after  repeated  overloading  of  the 
stomach  with  indigestible  food.  Long-continued  use  of  A^ery  salty 
or  acid  or  spiced  foods,  and  the  ingestion  of  very  hot  or  very  cold 
drinks  after  long  fasting,  and  in  debilitated  states  following  excesses 
in  Venere  et  Baccho.  It  has  been  obsers^ed  to  occur  also  after 
chloroform  narcosis.  Secondarv^  h^^peresthesia  occurs  with  hyper- 
acidity and  supersecretion  in  hysterical  patients,  also  in  neuras- 
thenia and  tabes.  Gastralgia  may  follow  hyperesthesia,  and  there 
are  cases  in  which  both  neuroses  may  exist  simultaneously. 

Symptomatology. — Patients  with  this  neurosis  frequently  feel 
the  pulsations  of  the  abdominal  aorta,  and  complain  of  beating  and 
pulsating  in  the  stomach.  Then,  again,  they  haA^e  a  feeling  of  heat 
or  cold,  or  a  gnawing,  burning  sensation,  and  an  impression  of  rest- 
lessness through  the  entire  stomach.  The  ingestion  of  food,  no 
matter  of  what  consistency,  causes  a  sensation  of  discomfort,  full- 
ness, nausea,  and  even  vomiting.  These  sensations  may  increase  to 
a  typical  gastralgia,  and  are  felt  only  during  the  first  period  of 
digestion,  or  they  may  last  as  long  as  food  is  contained  in  the  stomach. 
Some  patients  complain  for  a  while  even  after  food  has  left  the  stom- 
ach. The  pains  are  absent  in  the  morning,  when  the  stomach  is 
entirely  empty.  If  the  hyperesthesia  depend  upon  hyperch3dia,  the 
pains  do  not  become  pronounced  until  the  second  period  of  gastric 
digestion,  when  the  acidity  of  the  gastric  chyme  reaches  its  highest 
degree.  In  some  cases  of  hyperesthesia  it  may  happen  that  the  dis- 
tress is  temporarily  relieved  by  the  ingestion  of  albuminous  food  or 
the  taking  of  alkalies.  The  burning,  sticking,  and  beating  in  the 
stomach  may  be  accompanied  by  bulimia.     These  gastric  symptoms 


PROGNOSIS,    DIAGNOSIS,    AND   TREATMENT.  793 

are  generally  accompanied  b}^  other  nervous  phenomena  which  are 
probably  symptoms  of  the  fundamental  etiological  disease;  thus  we 
meet  with  migraine,  cephalalgia,  and  neuralgia  in  other  parts  of  the 
body,  etc.  The  emesis  which  occurs  in  hyperesthesia  induces  the 
patients  to  restrict  their  diet  more  and  more,  whereby  the  general 
nutrition  and  bodily  resistance  become  very  much  reduced.  Con- 
cerning the  appetite  and  the  foods  which  are  best  digested,  the 
patients  show  the  most  manifold  contrasts.  Some  of  them  feel  more 
distress  after  liquids  than  after  solids.  The  appetite  does  not  seem 
much  affected;  some  patients  have  an  intense  feeling  of  hunger. 
There  are  no  very  constant  anomalies  of  motility  or  secretion.  The 
bowels  are  generalty  constipated. 

Prognosis. — The  prognosis  is  favorable,  as  the  hyperesthesia 
ceases  when  the  detrimental  and  irritating  conditions  which  excite 
the  sensibility  of  the  stomach  can  be  kept  away,  and  when  the  funda- 
mental disease  can  be  removed. 

Diagnosis. — The  affection  may  be  confounded  with  gastralgia 
and  with  the  painful  symptoms  of  organic  gastric  diseases.  From 
gastralgia  it  can  be  distinguished  by  the  fact  that  the  symptoms  occur 
daily  for  a  long  time,  regularly  after  each  meal,  and  that  they  are  ab- 
sent when  the  stomach  is  empty.  Gastralgia  occurs  only  spasmodi- 
cally, rarely  lasts  longer  than  several  hours,  and  is  of  equal  severity  in 
an  empty  as  in  a  full  stomach.  The  intervals  between  the  attacks  are 
perfectly  free  from  gastric  distress.  Concerning  the  drfferential 
diagnosis  between  hyperesthesia  and  the  distress  of  diseases  of  the 
stomach  connected  with  anatomical  alterations,  we  refer  to  the  dift'er- 
ential  points  stated  in  the  diagnosis  of  gastralgia.  We  might  empha- 
size here  that,  in  the  organic  diseases,  the  pains  are  entirely  absent 
when  the  stomach  is  empty.  Atrophic  gastritis  forms  an  exception 
to  this  rule.  The  intensity  of  the  pains  is  influenced  by  the  quality 
of  the  food,  which  is  not  the  case  in  hyperesthesia,  and  that  organic 
diseases  are  mostly  associated  with  tolerably  constant  disturbances 
of  secretion  and  motility. 

Treatment. — The  treatment  will  be  directed  in  the  first  place  to 
the  correction  of  the  underlying  fundamental  disease.  Wherever 
this  is  not  possible,  or  wherever  an  idiopathic  form  of  hyperesthesia 
is  present,  all  irritants  which  can  exert  detrimental  influence  upon  the 
stomach  must  be  excluded.  All  bodily  and  mental  exertion  must  be 
avoided.  In  severe  cases  the  Weir  Mitchell  rest-cure,  together  with  a 
Leube  ulcer  cure,  has,  in  our  experience,  been  very  cfiicacious.     Hot, 


794  SENSORY   NEUROSES. 

moist  applications  to  the  stomach  are  very  soothing.  In  a  very  pro- 
nounced case  of  gastric  hyperesthesia  in  a  colleague,  which  returned 
regularly  whenever  he  was  under  great  mental  strain,  the  symptoms 
disappeared  entirely  after  a  sojourn  at  the  seashore  for  one  month. 
Galvanization  is  a  capital  method  of  treating  this  affection.  The 
intragastric  method  may  be  used,  but  when  the  patient  is  not  accus- 
tomed to  the  swallowing  of  the  electrode,  we  have  obtained  good 
results  from  the  external  application  of  the  large  abdominal  plates. 
Use  of  tea,  coffee,  tobacco,  and  alcohol  must  be  avoided,  as  these 
things  have  been  known  to  keep  up  a  hyperesthesia.  Rosenheim  has 
suggested  the  following  treatment  ("Berlin,  klin.  Wochenschr.," 
1890)  internally: 

R.      Argenti  nitras, 0.2  gr.  iij 

AquEe  menthas  pip., 100. o  S^^-     *       ^^ 

SiG. — Two  teaspoonfuls  in  a  wineglassful  of  water,  on  an  empty  stomach,  in  ihe 
morning,  and  a  half  hour  before  each  meal. 

The  patient  must  be  kept  in  bed,  and  warm  cataplasms  applied  to 
the  epigastrium.  The  diet  consists  of  milk  taken  by  tablespoonful 
doses,  later  on  soft  eggs,  and  scraped  beef  and  dipped  toast.  When 
the  stomach  becomes  more  resistant,  the  patient  ma}^  return  to  solid 
food.  To  remove  the  cause,  Rosenheim  advises  treatment  of  the 
general  underlying  affection,  bodily  and  mental  rest,  and  hydro- 
therapeutic  measures.  Severe  hyperesthesia  is  sometimes  relieved 
by  bromid  of  strontium  and  codein.  We  have  also  obtained  very 
good  results  from  spraying  the  stomach  with  a  solution  of  morphin, 
cocain,  and  menthol.  In  doing  this,  a  spray  must  be  used  by  which 
we  can  tell  the  exact  amount  of  cocain  and  morphin  which  reaches 
the  stomach  with  the  spraying  liquid.  It  is  well  not  to  put  more  into 
the  spray  than  we  wish  to  put  into  the  stomach,  otherwise  the  patient 
may  absorb  too  much  cocain  and  morphin. 

Gastric  idiosyncrasies  are  those  peculiar  forms  of  hyperesthesia 
in  which  neuropathic  and  sometimes  perfectly  healthy  persons  have 
morbid  sensations  only  after  ingesting  certain  foods.  These  sensa- 
tions consist  of  headache,  light  fever,  skin  erythema,  and  urticaria. 
The  author  has  observed  persons  who  developed  urticaria  after  eating 
crabs,  potatoes,  cheese,  or  strawberries.  One  of  our  patients  regu- 
larly develops  an  acute  acne  whenever  she  eats  cheese.  Another 
patient  regularly  develops  fever,  eructations,  nausea,  and  vomiting 
whenever  he  partakes  of  crabs.  Although  a  heightened  irritability  of 
the  sensory  nerves  may  be  instrumental  in  the  development  of  these 


GASTRALGIA.  795 

idiosyncrasies,  it  is  very  plausible  that  autointoxication  plays  a  very 
important  role  in  them.  It  is  probable  that  in  individuals  who  de- 
velop urticaria  after  eating  certain  foods,  there  must  be  microorgan- 
isms that  develop  toxins  from  these  foods  which,  in  turn,  act  in  the 
manner  indicated.  Pick  states  that  his  cases  suffered  also  from  con- 
stipation, which  naturally  favors  the  putrefaction  of  the  ingesta. 
Acting  upon  the  theory  of  autointoxication  caused  by  intestinal 
putrefaction.  Pick  very  strongly  recommends  the  internal  use  of 
creasote  (see  Albu,  "Autointoxicationen  des  Intestinaltractus,"  part 
on  The  Skin,  p.  88;  also  p.  396  of  this  volume),  which  in  my  expe- 
rience has  proved  useless.  The  correct  course  to  follow  is  to  avoid 
all  foods  entirelv  that  are  known  to  cause  such  distress. 


GASTRALGIA  (Cardialgia  ;  Gastrodynia). 

Gastralgia,  or  neuralgia  of  the  stomach,  occurs  in  periodical  and 
spasmodical  attacks  of  severe  gastric  pain,  alternating  with  intervals 
of  freedom  from  pain.  Pains  of  greater  or  less  intensity  occur  with 
all  gastric  diseases,  particularly  with  ulcer,  carcinoma,  gastritis 
atrophicans,  and  toxic  gastritis.  These  pains  are  a  consequence  of 
the  anatomical  alterations  which  these  organic  diseases  effect  in  the 
gastric  wall,  brought  about  most  probably  by  exposure,  distortion, 
and  compression  or  inflammation  of  the  sensory  gastric  nerves.  Such 
pains  have  been  described  in  the  chapter  on  various  Organic  Diseases 
of  the  Stomach.  Gastralgic  pain  results  from  functional,  not  from 
structural,  disturbances  of  the  sensory  nerves.  Gastralgia  is  charac- 
terized by  the  irregular  intervals  in  which  it  occurs,  and  its  inde- 
pendence of  the  qualit}^  and  quantity  of  the  ingesta.  The  attacks 
come  on  either  suddenly,  or  there  may  be  such  premonitory  symp- 
toms as  feeling  of  pressure  and  fullness  in  the  stomach,  eructation, 
nausea,  vomiting,  headache,  and  salivation.  The  pains  have  a 
gnawing,  boring,  burning,  tearing,  or  cramp-like  character.  They 
are  felt  principally  in  the  epigastric  region.  In  some  cases  the  pain 
radiates  to  the  hypochondriac  regions,  the  entire  abdomen  and  back, 
and  may  be  accompanied  by  unmistakable  signs  of  collapse  and  the 
feeling  of  impending  dissolution.  The  pains  occur  as  well  after  food 
that  is  easily  digestible  as  after  indigestible  food. 

In  some  hysterical  patients  the  so-called  "clavus  hystericus,"  a 
sharply  localized  pain,  as  if  a  nail  were  driven  into  a  part,  is  well  de- 
scribed by  the  sufferer.     There  is  also,  in  some  of  these  cases,  a  sud- 


796  SENSORY   NEUROSES. 

den  and  transient  sensation  as  if  a  tremendous  ball  were  rising  in  the 
throat  (globus  hystericus).  Nausea  and  vomiting,  as  well  as  bulimia 
and  an  urgent  desire  to  urinate,  are  occasional  symptoms.  The  par- 
oxysms may  last  a  few  minutes  or  several  hours,  and  extend  through 
the  entire  night;  they  may  begin  at  any  hour  of  the  day  or  night. 
The  intervals  of  relief  may  amount  to  days,  weeks,  or  months. 

Malaria. — We  have  observed  a  number  of  cases  of  malarial  gas- 
tralgia  in  which  the  attacks  occurred  at  regular  intervals,  and  could 
be  distinctly  associated  with  an  evolution  of  the  characteristic  mala- 
rial parasite  in  the  blood.  These  malarial  gastralgias  are  not  infre- 
quent in  fishermen,  and  even  in  sportsmen  who  sojourn  for  weeks 
along  the  shores  of  the  Chesapeake  Bay  in  Maryland.  In  a  patient 
of  this  city  the  gastralgic  attacks  persisted,  notwithstanding  the 
most  careful  treatment,  until  the  patient  could  be  persuaded  to  give 
up  his  ducking  sport  on  the  Chesapeake  Bay,  for  the  relief  afforded 
by  quinin  was  not  permanent.  The  attacks  occur  generally  without 
any  demonstrable  cause.  As  a  rule,  only  one  attack  occurs  in  the 
day,  but  there  may  be  as  many  as  four  in  one  day.  The  end  of  the 
attack  may  culminate  in  very  profuse  vomiting,  which  brings  a  great 
relief,  the  pains  ceasing  thereafter  as  rapidly  and  suddenly  as  they 
came  on.  Gastralgia  may  be  a  primary  idiopathic  and  independent 
disease  or  a  secondary  reflex  neurosis. 

Causation. — The  gastralgia  is  frequently  a  result  of  motor  or 
secretory  neuroses — of  gastrospasm,  pylorospasm,  and  cardiospasm, 
hyperacidity,  and  supersecretion.  The  root  of  the  vagus  nerve  may 
be  irritated  by  functional  and  anatomical  diseases  of  the  medulla  and 
adjacent  portions  of  the  central  nervous  system.  Boas  (l.  c,  ii, 
S.  214)  enumerates  the  following  causes  of  gastralgia:  (i)  Those  that 
attack  the  stomach  itself  and  its  immediate  surroundings.  (2)  Cen- 
tral causes.  (3)  Infections  and  intoxications.  (4)  Reflex  causes 
emanating  from  other  organs.  (5)  Neurasthenia  and  hysteria. 
(a)  The  causes  that  emanate  from  the  stomach  and  its  immediate 
surroundings  are  gastric  ulcer,  gastric  carcinoma,  gastritis  acida  and 
atrophicans,  various  forms  of  perigastritis,  and  peritonitic  adhesion 
with  the  pancreas,  liver,  gall-bladder,  spleen,  and  transverse  colon, 
and  other  portions  of  the  intestines.  Furthermore,  hypersecretion 
and  gastroxynsis,  tumors  of  neighboring  organs,  and  pancreatic  cysts. 
(6)^0f  the  central  causes,  he  mentions  the  attacks  occurring  with 
tabes  ("crises  gastriques").  In  myelitis  and  brain  tumors,  gastral- 
gic pains  have  been  observed,      (c)   Infections  and  intoxicants  may 


GASTRALGIA.  797 

cause  gastralgia.  Of  the  first,  a  prominent  cause  of  infection  in  our 
latitude  is  malaria,  either  in  its  outspoken  form  or  in  its  masked  and 
latent  type.  Of  intoxicants,  nicotin  poisoning  and  the  autointoxica- 
tion associated  with  uric  acid  and  gout  are  well-known  causative 
factors,  (d)  Among  the  reflex  causes  emanating  from  other  organs, 
diseases  of  the  genito-urinary  organs  occupy  the  first  place  in  both 
sexes.  Prominent  among  these  are  displacements  of  the  uterus,  in- 
flammations of  the  ovaries  and  tubes,  and  uterine  and  ovarian  neo- 
plasms. (Panecki,  "  Retro flexio  uteri  und  Magenneurosis,"  "Thera- 
peut.  Monatshefte,"  1892,  S.  79.)  Independent  organic  gastric  dis- 
eases that  occur  simultaneously  must  be  carefully  differentiated  from 
the  typical  gastralgia.  Gastralgias  may  be  associated  with  genito- 
urinary diseases  in  the  male.  (Peyer,  "Ueber  Magenaffectionen  b. 
mannlichen  Genitalleiden,"  "Volkmann's  Samml.  klin.  Vortr.,"  No. 
356.)  The  gastralgias  that  occur  as  a  consequence  of  enteroptosis 
have  been  fully  considered  in  the  chapter  on  Gastroptosis.  (e) 
Stomach  neuralgia  which  occurs  in  hysterical  and  neurasthenic  per- 
sons without  any  apparent  cause,  and  those  which  occur  in  anemic 
patients,  should  prompt  a  very  careful  examination  before  we  decide 
that  there  is  no  real  organic  trouble  at  the  foundation  of  the  gastral- 
gia. Occasionally  we  may  find  that  gastralgias  occur  with  small 
median  hernise  of  the  linea  alba.  Whenever  motor  insufficiency 
exists  with  these  hernias,  we  presume  that  the  omentum  is  fixed  in 
the  hernial  sac.  Such  cases  have  been  recently  reported  by  Charles 
D.  Aaron  and  Rosenheim  ("Berlin,  klin.  Wochenschr.,"  1897,  No. 
11).  Horner  ("Ueber  Cardialgia,  verursacht  durch  praperitoneale 
Lipome,"  "Prag.  med.  Wochenschr.,"  1892,  S.  310)  reports  a  case  of 
severe  gastralgia  caused  by  preperitoneal  lipomata.  These  herniae 
of  the  linea  alba  can  be  treated  successfully  only  by  an  operative  or 
orthopedic  method  (bandages). 

F.  Bardenhauer  ("Ueber  den  epigastrischen  medianen  Bauch- 
bruch,"  in  "Gesammelte  Beitrage  a.  d.  Gebiete  d.  Chir.  u.  Medizin," 
etc.,  Wiesbaden,  1893,  S.  35),  Vulpius  ("Beitr.  z.  klin.  Chirurg.," 
Ed.  VII,  H.  i),  and  Roth  ("Archiv  f.  klin.  Chirurg.,"  Bd.  xui,  H.i, 
S.  i)  consider  this  subject  from  the  surgical  side.  It  is  possible  that 
in  some  cases  of  gastralgia  in  which  we  can  not  find  other  diseased  con- 
ditions that  may  have  caused  the  affections,  secondary  anatomical 
changes  in  the  stomach  may  exist.  Among  these  are  erosions  with- 
out hemorrhage,  follicular  inflammation,  adhesions'  with  neighboring 


798  SENSORY   NEUROSES. 

organs,  and  cicatrices.*  These  conditions  can  not  be  excluded  with 
certainty,  because  they  may  not  cause  symptoms  for  a  long  time. 
Bverv^  caution  should  be  exercised  in  the  diagnosis  of  idiopathic  gas- 
tralgia,  as  many  a  case  that  is  diagnosed  as  a  genuine  form  of  gastral- 
gia  of  this  character  is  found,  after  a  very  thorough  examination,  to 
be  a  result  of  some  anatomical  change,  or  a  motor  or  secretory  neuro- 
sis of  the  stomach,  or  of  a  disease  of  some  other  organ.  Idiopathic 
gastralgia  should  be  diagnosed  only  when  symptoms  and  indications 
of  other  diseases  can  not  be  discovered  after  an  exhaustive  anamnesis, 
and  repeated  thorough  examinations,  and  instituted  during  the  inter- 
vals between  the  attacks  when  the  patient  is  free  from  suffering.  The 
author  has  rarely  made  the  diagnosis  of  idiopathic  gastralgia. 

Idiopathic  gastralgia  may  occur  in  connection  with  chlorosis, 
anemia,  chronic  nicotin  poisoning,  nephritis,  incipient  tuberculosis, 
and  convalescence  from  continued  fevers,  and  also  as  a  result  of  alco- 
holic and  sexual  excesses.  The  gastralgias  which  occur  with  arthri- 
tis, malaria,  and  chronic  rheumatism  are  particularly  interesting 
from  an  etiological  point  of  view.  We  have  repeatedly  obser\"ed  that 
gastralgic  attacks  in  gout  ma}^  take  the  place  of  an  expected  acute 
attack  of  the  joints.  The  association  of  malaria  with  gastralgia  can 
be  established  beyond  a  doubt  by  the  blood  examination  for  the 
malarial  parasite,  and  this  kind  of  gastralgia  can  be  cured,  by  the 
administration  of  quinin  and  sometimes  of  arsenic,  and  ceases  en- 
tirely if  the  patient  removes  to  an  environment  that  is  free  from 
malaria.  The  occurrence  of  gastralgia  during  gout  has  been  ex- 
plained by  some  by  assuming  that  the  deposits  of  uric  acid  and  uric 
acid  salts  actually  occur  in  the  walls  of  the  stomach  and  thereby 
irritate  the  endings  of  the  sensory  nerves.  This  theory  explains 
how  gastralgia  may  occur  vicariously  in  place  of  expected  attacks  of 
gout. 

Secondary  Gastralgia. — Cases  of  this  type  have  been  reported 
which  were  ver}^  severe  and  obstinate  during  life,  and  in  which  tumors 
were  found  at  the  autopsy  drawing  upon  or  compressing  the  fibers 
of  the  vagus  and  sympathetic.  It  has  been  observ^ed,  also,  in  Base- 
dow's disease,  but  is  more  frequently  the  result  of  direct  or  indirect 
irritation  of  the  roots  of  the  vagus  nerve  in  consequence  of  organic 

*  A  negro  suffering  from  the  most  intense  gastralgia  with  hyperacidity  was  operated 
on  at  the  Maryland  General  Hospital  by  Dr.  John  D.  Blake,  upon  the  author's  advice. 
The  stomach  was  bound  to  the  liver,  diaphragm,  and  transverse  colon  by  numerous 
adhesions,  those  going  to  the  liver  being  inseparable. 


DIAGNOSIS    OF    GASTRALGIA.  799 

or  functional  disease  of  the  spinal  cord  or  brain.  We  have  already 
referred  to  the  frequent  attacks  of  gastralgia  occurring  in  tabes,  which 
have  recently  been  explained  by  a  sclerotic  degeneration  of  the  nu- 
cleus and  of  the  main  stem  of  the  vagus  (Kahler,  Oppenheim,  De- 
mange,  Dejerine).  The  gastric  crisis,  which  we  have  described  else- 
where, demands  a  greater  interest  because  it  may  occur  in  tabes  as  an 
initial  symptom  when  the  other  characteristic  signs,  such  as  absence 
of  the  tendon  reflexes,  rigidity  of  the  pupils,  and  Romberg's  symp- 
tom, are  not  yet  present,  and  in  some  cases  the  typical  ataxia  has  not 
been  known  to  occur  for  from  six  months  to  a  year  after  critical  gas- 
tralgias  of  this  kind.  Erb  has  established  a  ver\-  probable  causal 
relation  between  syphilis  and  tabes,  and  the  hope  has  been  expressed 
that  these  early  gastric  crises  should  stimulate  exhaustive  clinical 
examinations  of  the  patients  with  a  view  to  combating  the  disease  by 
mercurv^  and  iodids  at  a  time  when  the  spinal  changes  are  not  far 
progressed.  Ley  den  has  described  gastralgia  with  subacute  myelitis, 
and  Oser  with  myelitis  due  to  compression. 

Symptomatology. — The  symptoms  of  the  attacks  are  generalh- 
quite  characteristic,  and  the  course  so  typical  that  they  can  not  be 
misinterpreted.  Prodromal  symptoms,  such  as  depressed  spirits, 
headache,  salivation,  nausea,  pressure,  and  fullness  in  the  stomach 
may  occur,  but,  as  a  rule,  are  not  observ^ed  and  have  no  diagnostic 
value.  Generally,  the  cases  begin  ven,^  suddenh^  with  severe  gastric 
pains,  which  are  sometimes  so  intense  as  to  bafiie  description.  Strong 
pressure  upon  the  stomach  sometimes  relieves  the  pain — in  fact,  the 
patients  are  often  found  doubled  up  in  bed,  pressing  both  hands  upon 
the  epigastrium.  If  the  pain  has  been  caused  by  hyperchylia,  it  is 
relieved  by  alkalies  or  albuminous  food.  The  bowels  are  constipated 
and  the  urine  is  suppressed.  The  forehead  is  covered  with  large  drops 
of  cold  perspiration,  the  pulse  is  small,  occasionally  irregular  and 
accelerated.  In  rare  cases  it  has  been  reported  to  have  been  much 
retarded.  Great  prostration  and  muscular  cramps,  and  even  general 
convulsions,  have  been  know^n  to  follow.  At  the  end  of  the  attack 
the  patients  usually  indulge  in  repeated  yawning,  eructation,  and 
sometimes  vomiting,  and  in  hysterical  patients  a  copious  dilute  urine 
is  sometimes  voided. 

Diagnosis. — As  idiopathic  gastralgia  can  rarely  be  logically  diag- 
nosed, it  will  be  more  correct  to  consider  gastralgia  as  a  symptom, 
not  as  a  disease  per  se;  although  the  fundamental  disease  causing  it 
may  remain  obscure  or  be  missed  entirely  in  the  beginning  of  the  dis- 


800  SENSORY    NKUROSES. 

ease,  it  may  become  pronounced  eventually.  Gastralgias  may  have 
to  be  differentiated  from  the  pain  of  ulcer,  acute  and  chronic  gastritis, 
toxic  gastritis,  carcinoma,  from  rheumatism  of  the  abdominal  mus- 
cles, myalgia,  intercostal  neuralgia,  nephrolithiasis,  cholelithiasis,  and 
intestinal  colic.  The  differential  diagnosis  from  ulcer  of  the  stom- 
ach has  been  stated  in  the  chapter  on  Ulcer.  The  ulcer  pain  is 
sharply  circumscribed  in  the  epigastrium  and  in  the  dorsal  regions. 
It  is  directly  dependent  upon  the  quantity  and  quality  of  the  food. 
Pains  from  gastric  ulcer  are  relieved  by  rest  in  bed,  and  made  worse 
by  movement.  This  pain  does  not  occur  in  paroxysms — it  is  usually 
a  lasting  discomfort.  There  may  be  atypical  cases  of  ulcer  in  which 
the  diagnosis  becomes  much  involved.  Boas  (Z.  c,  S.  38)  emphasizes 
the  diagnostic  value  of  the  painful  point  situated  at  the  left  of  the 
spinal  column  between  the  tenth  and  twelfth  thoracic  vertebrae  in 
cases  of  gastric  ulcer. 

Von  Leube  advises,  when  other  symptoms  are  missing,  to  treat 
the  disease  as  if  it  were  ulcer,  and  Boas  recommends  the  internal 
administration  of  nitrate  of  silver  for  three  or  four  weeks.  The 
good  result  of  both  of  these  treatments  would  speak  for  gastric  ulcer. 
The  acute  and  chronic  gastritis  are  rarely  so  painful  as  to  be  con- 
founded with  gastralgia.  The  pains  of  chronic  atrophic  gastritis 
occur  only  at  a  time  when  complete  atrophy  of  the  mucosa  has  super- 
vened; and,  inasmuch  as  the  secretion  in  gastralgia  is,  as  a  rule,  not 
suppressed  or  lost,  this  factor  will  constitute  an  important  diagnostic 
feature,  since  HCl  is,  in  a  great  majority  of  cases,  absent  in  gastritis. 
From  toxic  gastritis  the  diagnosis  is  made  by  help  of  the  clinical  his- 
tory ;  from  carcinoma,  by  means  of  ascertaining  the  state  of  the  mo- 
tility and  secretion,  which  is,  as  a  rule,  lost  in  carcinoma,  ■  and  normal 
in  gastralgia.  The  pains  of  carcinoma  as  well  as  of  ulcer  increase  on 
pressure;  in  gastralgia  they  diminish  on  pressure,  and  in  carcinoma 
we  have  anemia  and  cachexia  as  prominent  signs.  It  has  been  said 
that  the  galvanic  current,  with  the  anode  on  the  epigastrium  and  the 
cathode  on  the  spinal  column,  relieves  the  pain.  These  signs  are  not 
reliable,  and  as  there  is  nothing  typical  about  gastralgic  attacks 
which  should  distinguish  them  from  painful  paroxysms  issuing  from 
other  abdominal  organs,  we  may  say  that,  up  to  the  present  time,  no 
pathognomonic  sign  or  symptom  of  gastralgia  exists.  There  are 
attacks  of  rheumatism  and  myalgia  of  the  abdominal  muscles  which 
seem  to  become  focused  in  the  upper  part  of  the  abdomen,  so  that 
they  may  be  confounded  with  gastralgic  pains.     Myalgic  pains  may 


TREATMENT    OE    GASTRALGIA.  8oi 

occur  from  severe  exertion  of  the  abdominal  musculature.  These 
pains  are  increased  by  pressing  or  pinching  the  sore  muscles;  they 
are  not  accompanied  by  any  gastralgic  symptoms  whatever,  are  very 
much  improved  by  rest,  and,  if  they  are  rheumatic,  by  salol  and  sali- 
cylate of  soda.  Intercostal  neuralgias  can  be  distinguished  by  the 
excessive  and  permanent  sensitiveness  to  pressure  which  the  affected 
nerves  exhibit  all  along  their  course  from  the  spinal  column  to  the 
sternum.  Cholelithiasis  or  the  pains  of  an  incarcerated  or  passing 
gall-stone  frequently  irradiate  so  prominently  to  the  epigastric  region 
that  they  are  more  marked  there  than  over  the  liver,  but  whenever 
the  stone  obstructs  the  ductus  choledochus  temporaril}^,  the  gall- 
bladder may  be  palpable  by  its  dilation,  and  icterus  and  clay-colored 
stools  are  evident  signs;  but  in  those  patients  in  which  the  stone  is 
impacted  in  the  cystic  duct  and  does  not  completely  obstruct  it,  or 
rapidly  passes  through  it,  a  differential  diagnosis  is  difficult,  because 
the  symptoms  before  mentioned  are  absent.  But  even  in  these  cases 
great  sensibility  of  the  liver  to  pressure,  anteriorly  and  posteriorly,  is, 
as  a  rule,  present.  The  liver  is  usually  enlarged,  and  there  is  a  painful 
point  in  cholelithiasis  at  the  twelfth  dorsal  vertebra,  a  few  centi- 
meters to  the  right  of  the  spinal  column.  A  careful  search  for  gall- 
stone particles  must  be  made  in  the  passages.  Gall-stones,  as  a  rule, 
cause  vomiting,  while  gastralgia  rarely  does  so.  The  differential 
diagnosis  between  hepatalgia  and  gastralgia  presents  great  difficul- 
ties. In  nephritic  colic  the  dyspeptic  symptoms  may  be  exactly 
like  those  of  gastralgia.  The  diagnosis  between  the  two  affections 
can  be  .made  with  certainty  by  careful  urinary  examination  for  frag- 
ments of  calculi  and  traces  of  blood,  or  by  catheterization  of  the 
ureters  in  the  intervals,  and  occasionally  by  localizing  the  renal  cal- 
culus by  the  Rontgen  rays.  (See  Teonard,  Chas.  T.,  "The  X-ray 
Diagnosis  of  Nephrolithiasis,"  "Phila.  Med.  Jour.,"  vol.  v.  No.  i,  p. 
50,  Jan.,  1900.)  In  intestinal  colic  the  pains  may  be  located  in  the 
upper  part  of  the  abdomen.  They  are  mostly  due  to  excessive  gas- 
eous distention  of  the  intestinal  loops,  and  are  associated  with  consti- 
pation, and  cease  after  the  copious  discharge  of  gas. 

Treatment. — In  the  treatment  of  gastralgia  the  fundamental 
cause  must,  if  possible,  be  discovered  and  removed.  In  malarial  dis- 
tricts the  treatment  by  quinin  and  tonics  is  the  most  eft'ective,  if  the 
causal  relation  can  be  established.  Chlorosis  and  anemia  should  be 
treated  by  albuminate  or  peptonate  of  iron,  ferratin,  bone-marrow, 
arsenic,  and  highly  nutritious  diet.     In  some  cases  there  is  no  better 


802  SENSORY   NEUROSES. 

remedy  than  the  tincture  of  the  chlorid  of  iron.  If  the  patient  is  an 
inveterate  smoker,  he  must  be  cautioned  to  cease  his  habit.  Entero- 
ptosis,  gout,  and  rheumatism  must  have  suitable  therapeutic  atten- 
tion. Disturbances  of  the  genito-urinary  organs,  particularly  of  the 
female  sexual  organs,  will  command  the  attention  of  the  specialist. 
Wherever  we  can  find  no  cause  for  gastralgia,  the  only  thing  that  can 
be  done  is  to  treat  it  symptomatically.  The  most  effective  agent  in 
our  experience  for  this  purpose  has  been  the  galvanic  current.  Large, 
felt-covered,  copper  plates  are  dipped  in  water  as  hot  as  the  patient 
can  bear  it,  the  anode  placed  on  the  epigastrium  and  the  cathode  on 
the  spinal  column,  extending  from  the  cervical  region  downward 
between  the  scapulae.  For  this  purpose  we  use  very  strong  currents 
— not  less  than  twenty-five  milliamperes.  Oser  (' '  Die  Neurosen  des 
Magens,"  etc.,  Vienna  and  Leipsic,  1885)  claims  to  have  observed 
cessation  of  the  pains  after  application  of  the  faradic  current.  When 
the  pains  are  not  too  intense,  the  internal  administration  of  phosphate 
of  codein,  ^  of  a  grain  every  three  hours,  chloral  hydrate,  fifteen  grains 
every  two  hours,  Dover's  powder,  tincture  or  extract  of  hyoscyamus, 
extract  of  belladonna,  and  camphorated  tincture  of  opium  are  availa- 
ble remedies.  Compound  spirits  of  ether  and  the  ethereal  tincture 
of  valerian,  twenty  drops  every  two  hours,  are  useful  when  collapse  is 
associated  with  the  pain.  Exalgin,  antipyrin,  and  antifebrin  have 
been  recommended  by  Penzoldt.  If  the  collapse  is  marked,  wine, 
whisky,  ether,  and  ammonia  should  be  given  until  it  has  passed  over. 
In  pains  of  great  intensity,  the  sovereign  remedy  is  a  hypodermic 
injection  of  ^  of  a  grain  of  morphin  sulphate,  together  with  y^Q-  of  a 
grain  of  atropin  sulphate  injected  directly  into  the  epigastric  region. 
Boas  recommends  suppositories  of  extract  of  opium  and  extract  of 
belladonna.  All  of  these  agents  are  useful  for  the  immediate  treat- 
ment of  a  paroxysm ;  they  probably  have  no  curative  effect  on  the 
underlying  etiological  trouble.  The  irritability  of  the  mucosa  can 
be  effectively  reduced  and  gastralgic  attacks  sometimes  altogether 
prevented  from  recurring  by  intragastric  irrigation  with  lukewarm 
carbonated  water  (Malbranc,  Kussmaul),  or  by  treating  the  mucosa 
according  to  Kleiner's  method — with  suspensions  of  bismuth  sub- 
nitrate.  We  have  seen  excellent  results  from  irrigations  containing 
bismuth  subnitrate  (5ij),  bismuth  subgallate,  p5ss  in  one  pint  of 
camphor  water.  The  outflowing  camphor  water  must  be  measured 
so  as  to  ascertain  that  not  over  5j  remains  in  the  stomach.  Although 
the  pains  of  gastralgia  are  not  influenced  directly  by  the  character  of 


BULIMIA,    OR   HYPEROREXIA.  803 

the  food,  the  diet  should  be  very  bland  and  unirritating,  and  should 
not  be  taken  in  large  quantities. 

Gastralgokenosis. — Under  this  name  Boas  describes  a  painful 
emptiness  of  the  stomach  which  occurs  one  to  two  hours  after  meals, 
and  may  be  so  severe  as  to  embarrass  the  respiration  of  the  patient. 
The  paroxysms  last  but  one-quarter  to  one-half  an  hour,  and  are  not 
connected  with  bulimia.  These  attacks  are  said  to  be  relieved  by  the 
ingestion  of  milk,  bread,  etc.  One  of  the  cases  of  Boas  developed 
into  an  attack  every  time  he  drank  wine  or  champagne  or  ate  cake. 
We  have  never  seen  a  case  that  corresponds  to  Boas'  description  of 
this  malady,  and  would  suggest  that  it  is  probably  a  gastric  hyper- 
esthesia associated  with  hyperperistalsis  and  a  strong  secretion  of 
HCl,  particularly  as  the  cases  reported  by  Boas  show  that  the  reac- 
tions for  HCl  were  quite  marked. 


ANOMALIES    OF   THE   SENSATIONS   OF  HUNGER  AND 

APPETITE. 

BULIMIA,  OR  HYPEROREXIA. 

Morbid  increase  of  the  sensation  of  hunger  may  occur  as  an  inde- 
pendent idiopathic  neurosis,  as  a  result  of  abnormal  irritability  of  the 
center  controlling  the  sensation  of  hunger,  or  as  a  symptom  of  organic 
diseases.  An  intelligent  insight  into  the  pathogenesis  of  bulimia  is 
possible  only  with  a  knowledge  of  the  origin  of  the  sensation  of  hun- 
ger. .  A  modern  physiological  theory  suggests  that  the  hunger  center 
in  the  medulla  oblongata  is  stimulated  normally  by  the  blood  as  soon 
as  it  has  become  impoverished  in  nutritive  substances,  and  that  the 
sensation  of  hunger  ceases  when  the  blood  is  saturated  with  nutritive 
substances.  Stiller  and  others  assert  that  the  sensation  of  hunger 
results  from  excitation  of  specific  hunger  nerves  in  the  stomach,  and 
that  from  here  the  sensation  is  conducted  centripetally  to  the  hunger 
center,  and  that,  therefore,  the  normal  sensation,  as  a  rule,  is  brought 
to  consciousness  indirectly.  Neither  of  these  theories  is  supported 
by  satisfactory  clinical  and  experimental  evidence.  The  appetite 
ceases  when  the  stomach  is  filled  with  food,  but  that  does  not  imply 
that  the  nutritive  materials  are  already  absorbed  into  the  blood. 
This  may  require  from  three  to  four  hours.  In  many  gastric  diseases 
the  feeling  of  hunger  is  indirectly  affected  by  the  local  disease,  either 
increased  or  diminished.     There  are  also  general  (metabolic)  diseases 


8o4  SENSORY  NEUROSES. 

which  directly  or  indirectly  increase  or  diminish  the  sensation  of 
hunger.  In  some  persons,  even  in  the  normal  condition,  vehement 
emotional  excitations  may  cause  a  loss  of  hunger  and  appetite, 
although  the  blood  is  undoubtedly  impoverished  in  nutritive  sub- 
stances, so  that  we  have  clinical  evidence  sufficient  to  demonstrate  a 
local,  gastric,  and  a  remote  or  central  nervous  excitation  of  hunger. 
According  to  one  hypothesis,  hunger  results  every  time  the  stomach 
becomes  entirely  empty,  and  Leo  ("Ueber  Bulimia,"  "Deutsche  med. 
Wochenschr.,"  1889,  Nr.  29  und  30)  has  asserted,  in  a  most  compre- 
hensive report  on  this  affection,  that  the  abnormally  rapid  evacua- 
tion of  the  stomach  is  the  cause  of  bulimia.  This  would  naturally 
include  that  bulimia  is  very  frequent  with  pyloric  insufficiency,  in 
which,  as  we  know,  the  ingesta  at  once  enter  the  intestine  from  the 
stomach.  Bulimia  should  also  then  be  frequent  in  cases  where  a 
gastroenterostomy  has  been  executed  for  benign  stenosis  of  the  pylo- 
rus; this  is  not  the  experience  of  the  author  with  his  cases  of  this 
class.  Ewald  and  Fleischer  have  reported  cases- of  bulimia  in  which 
there  was  no  hypermotility.  The  combination  of  bulimia  with  hy- 
permotility  may  possibly  be  explained  by  the  fact  that  intense  ex- 
citation of  the  hunger  center  may  extend  to  neighboring  centers  in 
the  medulla,  and  involve  even  the  vagus  center,  which  responds  by 
affecting  a  more  rapid  evacuation  of  the  gastric  contents  into  the  in- 
testines. Some  of  the  accompanying  symptoms  of  bulimia  (tinnitus 
and  roaring  in  the  ears,  palpitation  of  the  heart,  and  fainting)  are 
attributed  by  R.  Ewald  (the  physiologist)  to  secondary  irritation  of 
nervous  centers  lying  in  close  proximity  to  the  hunger  center.  The 
affection  expresses  itself  by  violent  sensations  of  hunger  coming  on 
suddenly,  even  shortly  after  the  completion  of  a  full  meal,  and  if  the 
desire  for  food  is  not  immediately  gratified,  the  patients  exhibit  signs 
of  weakness,  headache,  pallor  of  the  face,  palpitation  of  the  heart, 
roaring  noises  in  the  ears,  and  gastric  distress.  The  attacks  may 
sometimes  occur  periodically,  but,  as  a  rule,  occur  irregularly.  In 
the  intervals  between  the  attacks  hunger  and  appetite  are  normal, 
but  there  are  cases  in  which  bulimia  may  alternate  with  anorexia. 

Causation. — Bulimia  may  be  an  idiopathic,  central  neurosis  con- 
nected with  abnormal  irritability  of  the  hunger  center,  or  a  symp- 
tomatic affection  which  Leo  (/.  c.)  has  observed  in  exophthalmic 
goiter,  with  gastric  ulcer  and  hyperacidity,  chronic  gastritis,  tape- 
worm, diarrhea,  and  menorrhagia.  It  has  been  observed  even  with 
carcinoma  and  dilation.     Fleischer  states,  without  reserve,  that  the 


CAUSATION    OF    BULIMIA.  805 

hyperexcitability  of  the  hunger  center  is  not  caused  by  sudden  and 
excessive  impoverishment  of  the  blood  in  nutritive  substances,  be- 
cause the  attacks  may  occur  immediately  after  an  abundantly  nutri- 
tious meal  which  has  brought  about  a  feeling  of  satiety,  and  because, 
in  other  cases,  the  morbid  sensation  may  be  relieved  by  a  mouthful  of 
bread  or  a  swallow  of  beer  or  wine.  The  fact  that  the  sensations  of 
hunger  and  thirst  are  normal  in  the  intervals  between  the  attacks,  or 
even  at  times  entirely  absent,  argues  against  the  assumption  that 
bulimia  is  always  caused  by  a  condition  of  the  blood  acting  upon  the 
central  nervous  system.  The  following  are  morbid  conditions  in 
which  bulimia  has  been  observed  to  occur :  Cerebral  tumors,  epilepsy, 
psychoses,  hysteria  and  neurasthenia,  focal  diseases  of  the  brain, 
cerebral  concussion,  Basedow's  disease,  Addison's  disease,  tuberculo- 
sis, syphilis  (according  to  Fournier,  "Gazette  Hebdom.,"  1871,  No. 
1-3,  it  occurs  between  the  third  and  sixth  month  of  this  disease),  dia- 
betes mellitus,  uterine  disease,  chronic  gastritis,  ulcer,  dilation,  car- 
cinoma, enteritis,  and  intestinal  parasites.  Bulimia  has  also  been 
observed  during  the  puerperium.  Some  authors  classify  the  raven- 
ous appetite  following  exhaustive  continued  fevers,  as  well  as  that 
following  abundant  loss  of  blood,  with  bulimia.  This,  in  our  opinion, 
is  not  a  justifiable  classification,  because  the  increase  of  hunger  in 
these  cases  can  be  explained  in  a  simple  and  natural  way  without  as- 
suming a  hypothetical  excitability  of  the  hunger  center.  In  diabetes 
mellitus  we  may  assume  the  existence  of  an  abnormal  irritability  of 
the  hunger  center  because  these  patients  are  not  satisfied  even  shortly 
after  large  meals.  It  has  been  supposed  that  the  glucose  circulating 
in  the  blood  is  the  agent  that  causes  this  irritation  of  the  hunger 
center.  In  diabetic  patients  in  which  the  sugar  in  the  blood  and 
urine  has  been  reduced  by  a  diet  limited  exclusively  to  fat  and  albu- 
minous food,  the  torturing  feelings  of  hunger  disappear,  to  return 
again  if  the  mellituria  is  allowed  to  increase  on  other  diet.  According 
to  Pettenkofer  and  Voit,  the  metaboHsm  of  diabetic  patients  is  much 
increased ;  which,  of  course,  means  a  more  rapid  consumption  of  the 
nutritive  elements  of  the  blood.  The  impoverishment  of  the  blood 
is  further  augmented  by  the  fact  that  the  sugar  which  is  formed  from 
the  amylaceous  substances  of  the  food  is  only  partially  or  not  at  all 
utilized  in  the  economy.  The  diagnosis  of  bulimia  should  only  be 
made  in  diabetes  if  the  violent  sensations  of  hunger  continue  notwith- 
standing very  rich  and  very  abundant  meals,  or  if  it  recurs  very  soon 
after  such  meals,  by  which  the  blood  must  have  been  charged  with 


8o6  SENSORY   NEUROSES. 

nutritive  substances  for  a  longer  time.  Kwald  and  Boas  have  ob- 
served that  the  attacks  become  less  frequent  after  bodily  exercise  in 
the  open  air.  According  to  Rosenthal,  the  affection  is  more  frequent 
in  women  than  in  men,  and  occurs  most  often  between  the  twentieth 
and  fortieth  years. 

Symptomatology. — The  main  and  most  characteristic  symptom 
is  the  impulsive  sensation  of  hunger,  which  by  any  and  every  means 
commands  the  ingestion  of  food.  The  pallor,  weakness,  and  terror, 
with  attacks  of  fainting  and  roaring  in  the  ears,  we  have  already  de- 
scribed. This  sensation  comes  on  generally  within  one  to  two  hours 
after  meals,  but  it  may  occur  within  ten  minutes  after  meals.  We 
have  known  three  old  gentlemen  who  were  for  a  long  time  aroused  in 
the  middle  of  the  night  by  this  torturing  sensation  of  hunger.  Some 
patients  complain  of  gnawing  and  boring  pain  if  the  hunger  is  not 
gratified.  Very  small  quantities  of  milk,  beer,  or  wine,  or  only  a  few 
mouthfuls  of  cracker  or  bread,  will  cause  the  entire  train  of  symp- 
toms to  disappear.  Peyer  ("Correspondenzbl.  Schweitzer  Aerzte," 
1888,  Nr.  20)  reports  a  case  of  a  paroxysm  of  bulimia  occurring  in  a 
female  patient  when  she  was  away  from  home  visiting  a  friend.  The 
weakness  ensuing  is  described  as  having  been  so  great  that  she  could 
not  return  home.  Peyer  asserts  that  in  three-quarters  of  an  hour 
she  consumed  three  pints  of  milk,  twenty-three  eggs,  and  two  pints  of 
strong  wine  before  the  bulimia  and  pain  in  the  stomach  ceased.  The 
patient  then  fell  asleep,  and  on  awakening  returned  home  perfectly 
well.  Potton  reports  the  case  of  a  young,  hysterical  girl  who  was 
obliged  to  take  eleven  or  twelve  meals  a  day,  and  even  eat  during  the 
night ;  she  is  claimed  to  have  ingested  between  ten  and  twelve  kilo- 
grams of  food  per  diem,  and  was  finally  cured  by  gradually  increasing 
doses  of  morphin.  This  was  a  case  of  so-called  continued  bulimia. 
We  have  made  studies  of  the  dietary  in  two  of  our  cases,  a  male  and  a 
female  patient,  and  controlled  the  metabolism  by  determinations  of 
the  total  nitrogen  output  in  the  urine  and  feces.  The  man  took  in 
food  amounting  to  7368  calories  on  an  average,  daily;  the  woman 
consumed  food  to  the  value  of  8131  calories.  The  curious  observa- 
tion made  was  that  both  patients  lost  weight,  and  the  stools  contained 
from  ^  to  ^  of  the  ingested  food-stuffs  in  an  undigested  form.  The 
female  was  not  cured,  but  the  man  gave  himself  up  to  strict  sana- 
torium management — his  diet  was  gradually  reduced  to  2400  calo- 
ries ;  under  this  food  value  he  gained  weight,  and  the  urine  contained 
less  of  toxic  products  than  on  his  old  bulimic  food  supply.     Medicines 


DIAGNOSIS    OF    BULIMIA.  807 

were  not  used;  he  was  simply  put  under  constant  guard,  day  and 
night,  by  reliable  nurses,  and  no  more  food  allowed  than  was  ordered 
by  the  physician. 

Diagnosis. — Wherever  the  abnormal  sensation  of  hunger  occurs 
shortly  after  abundant  food  has  been  taken,  the  diagnosis  is  not  diffi- 
cult ;  at  other  times  it  may  be  confounded  with  polyphagia  and  acoria. 
In  polyphagia  the  desire  for  eating  is  vers'  much  increased,  but  it  does 
not  occur  until  some  time  after  the  meals,  and  occurs  gradually,  not 
developing  the  intense  hunger  suddenly.  So,  polyphagia  is  simple 
increase  of  the  normal  sensation  of  appetite,  such  as  we  find  in  dia- 
betes mellitus.  It  is  impossible  strictly  to  separate  polyphagia  from 
bulimia — both  occur  under  similar  conditions  and  as  primars'  or  sec- 
ondary neuroses.  Bouveret  ("Traite  des  Maladies  de  I'Estomac," 
Paris,  1893,  page  654)  refers  to  a  case  in  which  a  patient  seventeen 
years  old  could  devour  loo  pounds  of  meat  in  twenty -four  hours,  and 
Rosenthal  reports  an  instance  of  a  woman,  aged  twenty-eight  years, 
who  ate  at  one  meal  a  whole  roast  of  goose  and  a  large  portion  of 
bread.  There  is  a  so-called  continued  form  of  bulimia  which  alter- 
nates with  acoria,  or  the  absence  of  the  feeling  of  gratification  or 
satisfaction  after  meals.  If  it  can  be  found  that  the  feeling  of  hunger 
is  very  great,  and  even  continues  or  returns  after  abundant  meals, 
then  we  are  dealing  with  bulimia ;  but  if  the  sensation  of  hunger  is 
normal  or  reduced,  and  ceases  after  larger  meals,  but  without  causing 
the  feeling  of  satiety,  we  are  dealing  with  acoria.  The  continued 
form  of  bulimia  has  hitherto  been  found  only  with  diabetes  mellitus 
and  hysteria.  We  have  had  two  cases  in  hospital  practice  which 
illustrate  that  bulimia  and  polyphagia  may  be  developed  by  practice. 
Both  cases  occurred  in  negroes  who  had,  as  a  result  of  a  number  of 
wagers,  eaten  large  quantities  of  food.  One  colored  man  was  a  waiter 
at  a  hotel  at  Cape  May,  N.  J.,  and  made  a  practice  of  exhibiting  him- 
self by  eating  a  huge  watermelon  together  with  eight  pies.  The  other 
negro,  who  was  a  patient  at  Baltimore,  gradually  developed  his  poly- 
phagia from  participating  in  rival  encounters  with  other  indi\'iduals 
of  his  race  to  see  who  could  eat  the  most  oysters.  It  is  claimed  that 
this  man  could  eat  three  quarts  of  oysters,  with  a  large  amount  of 
crackers  and  beer.  Both  negroes  found  later  that  the  habit  had  de- 
veloped into  a  disease,  the  tremendous  appetite  developing  very 
often  within  a  hah  hour  after  the  big  meals  of  bread,  fish,  and  egg 
had  been  taken.  One  of  them  has  been  cured  by  dram  doses  of 
bromid  of  ammonia  four  times  daily.     The  diagnosis- of  an  affection 


8o8  SENSORY   NEUROSES. 

of  this  character  can  not  be  stated  in  such  exact  terms  as  that  of  an 
organic  disease,  as  individual  opinions  of  specialists  as  to  what  really 
constitutes  bulimia  will  probably  vary  greatly.  (The  treatment  will 
be  considered  together  with  that  of  acoria.) 

ACORIA. 

This  word  is  derived  from  «  and  yopiwuiu,  I  become  satiated. 

"Acoria"  denotes  the  absence  of  the  normal  feeling  of  satiation, 
even  after  very  abundant  meals,  without  increase  of  hunger  or  appe- 
tite. 

Acoria  is  not  identical  with  bulimia  or  polyphagia,  for  in  both  of 
these  there  is  a  very  strong  feeling  of  hunger,  while  in  acoria  we  may 
have  absence  of  appetite.  Even  in  polyphagic  gluttons  the  feeling  of 
satiation  will  eventually  supervene,  but  not  in  acoria.  The  disease 
is  generally  secondary  to  neurasthenia,  hysteria,  and  certain  psy- 
choses. It  is  occasionally  met  with  in  sexual  neurasthenics.  The 
feeling  of  satiation  is  no  positive  sensation ;  it  occurs  when  hunger  and 
appetite  have  been  appeased,  and  is  therefore  a  negative  sensation. 
Hunger  and  appetite  cease  normally  when  the  hunger  center  passes 
from  a  sensation  of  excitation  to  that  of  rest.  The  amount  of  food 
required  to  accomplish  this  varies  greatly  in  different  persons,  and 
even  in  the  same  person  at  different  times.  One  hypothesis  has  at- 
tempted to  explain  acoria  on  the  basis  of  overexcitation  of  the  hunger 
center.  If  this  were  the  case,  we  would  find,  periodically  at  least,  an 
increased  sensation  of  hunger  after  large  meals,  which  is  never  ob- 
served in  acoria,  for  hunger  and  appetite  are  normal,  or  even  subnor- 
mal, in  acoria.  Some  patients  even  state  that  after  meals  hunger 
ceases,  but  they  have  no  feeling  of  satiation;  in  fact,  no  impression 
whatever  from  the  stomach  informing  them  that  they  have  eaten 
enough.  It  is  well  known  that  many  people  are  not  satisfied  to  in- 
troduce food  until  the  appetite  has  been  appeased,  but  they  continue 
long  enough  to  perceive  a  feeling  of  pressure  and  slight  fullness  in  the 
stomach,  which  is  a  result  of  a  moderate  distention  of  the  gastric 
walls  by  ingesta.  While  moderate  eaters  perceive  this  sensation  as 
uncomfortable  and  indicating  supersatiation,  gormandizers  gradually 
become  accustomed  to  this  feeling  of  pressure  and  fullness,  sometimes 
from  early  childhood,  so  that  eventually  they  do  not  believe  them- 
selves satiated  before  this  distention  occurs,  and  this  fullness  and 
distention  are  finally  confounded  with  the  normal  sensation  of  satiety. 

The  next  step  in  the  development  of  this  nervous  anomal)^  is  that 


SYMPTOMATOLOGY   OF    BULIMIA.  809 

the  feeling  of  pressure  and  fullness  may  mimic  a  temporary  normal 
feeling  of  satiation,  while  at  the  same  time  the  excitation  of  the  hun- 
ger center  continues.  The  sensation  of  hunger,  when  it  is  not  vers'- 
strong,  may  be  in  some  cases  removed  by  filling  the  stomach  with  per- 
fectly indigestible  material,  such  as  leaves  and  sawdust.  In  the  voy- 
age of  the  Jeanette  (Journal  of  Lieutenant  de  Long,  commanding  the 
expedition,  1883)  the  surviving  members  of  the  crew  subsisted  upon 
scraps  of  deer  skin,  which,  from  its  bulk  in  the  stomach,  seemed  to 
afford  relief  from  hunger.  After  ever3^thing  was  exhausted  they  lived 
upon  an  infusion  made  from  arctic  willow,  containing  really  no  nour- 
ishment, and  ate  two  old  boots.  As  the  feeling  of  satiation  is  absent 
after  copious  filling  of  the  stomach  with  food,  and  as  it  can  not  be 
disguised  by  an  abnormal  feeling  of  hunger,  because  hunger  is  normal 
or  subnormal  in  acoria,  another  explanation  that  has  been  offered 
for  this  nervous  affliction  is  that  it  is  due  to  loss  of  sensibility,  or 
anesthesia,  of  the  gastric  sensory  nerves.  This  seems  to  be  a  very 
probable  explanation,  since  we  have  personally  had  at  least  one  ex- 
perience that  would  suggest  a  local  gastric  anesthesia  as  an  explana- 
tion of  acoria.  The  case  we  have  in  mind  is  that  of  a  young  woman 
whose  stomach  we  had  sprayed  with  a  three  per  cent,  solution  of 
cocain  and  menthol.  She  returned  on  the  same  day,  stating  that, 
although  she  had  taken  a  long  bicycle  ride  after  the  spraying,  and  re- 
turned home  feeling  quite  hungry,  she  had  the  impression  that  the 
food  she  ate  never  reached  the  stomach.  She  had  no  feeling  in  her 
stomach  that  the  meal  effected  satiation.  At  first  we  overlooked 
the  causal  relation  between  the  spraying  with  menthql  and  cocain  for 
this  temporar}^  acoria,  and  our  attention  was  attracted  to  it  after  the 
same  symptoms  were  complained  of  each  time  the  menthol  and  cocain 
were  used.  These  agents  had  been  emplo^^ed  for  the  relief  of  gas- 
tralgic  pains  resulting  from  erosions.  The  case  ultimately  recovered 
by  treating  it  with  suspensions  of  subnitrate  of  bismuth.  It  is  con- 
ceivable that  anesthesia  of  the  stomach  nerves  may  occur  from  re- 
peated overdistention,  as  occurs  in  bulimia,  polyphagia,  diabetes 
mellitus,  and  dilation  of  the  stomach. 

Symptomatology. — As  the  only  symptom  is  the  absence  of  satia- 
tion, the  clinical  picture  is  not  very  manifold.  The  complaints  of  the 
patients  are  limited  to  the  statement  that  large  meals  cause  no  sensa- 
tion of  having  had  enough  to  eat,  and  that  they  do  not  know  when 
to  cease  eating ;  that  they  have  to  measure  out  their  food  previous  to 
beginning  to  eat,  in  order  to  know  when  they  have-  had  sufficient. 


8lO  SENSORY   NEUROSES. 

Some  of  these  patients  try  to  compel  a  feeling  of  satiation  b}'  tlie 
ingestion  of  enormous  quantities  of  food  and  drink.  This  has  been 
reported  as  a  cause  of  gastritis,  atony,  and  dilation.  The  prognosis 
varies  according  to  the  fundamental  disease.  The  diagnosis  is  made 
from  the  single  important  symptom  and  the  exclusion  of  bulimia  and 
polyphagia.  Sometimes  we  find  transitions  from  acoria  to  bulimia, 
which  Boas  explains  by  a  reactive  hyperesthesia  following  an  anesthe- 
sia of  the  gastric  nerves.  Acoria  is  distinguished  from  polyphagia 
by  the  increased  desire  for  food,  which  is  marked  in  the  latter,  very 
likely  as  a  result  of  increased  oxidation,  while  the  diagnosis  from  buli- 
mia hinges  upon  the  ravenous  desire  for  food  in  the  latter;  in  both 
the  feeling  of  satiation  will  eventually  super\^ene. 

Treatment. — The  treatment  of  bulimia  when  it  is  a  secondar}^ 
disease  must  have  regard  for  removal  of  the  primary  cause,  such  as 
intestinal  parasites,  genito-urinar}"  diseases,  hyperacidity,  or  ulcer, 
and  any  existing  neurasthenia,  hysteria,  or  psychosis.  The  bromids 
are  ver}^  valuable  remedies  to  reduce  the  irritability  of  the  hunger 
center;  they  should  be  given  in  the  form  of  bromid  of  ammonia  or 
strontium,  thirty  grains  of  either  four  times  a  day,  preferably  in  pep- 
permint water.  The  foUowing  formula  will  be  found  useful  in  buli- 
mia: 

K-      Tinct.  opii  camph., Sl.o  fsiij 

Tinct.  belladonnse, i.o  gtt.  xl 

Elix.  simplic, q.  s.  180.0  ^B^h  •^• 

SiG. — One-half  of  a  fluidounce  three  times  a  day. 

Arsenic,  in  form  of  Fowler's  solution,  beginning  with  three  to  five 
drops,  and  gradually  increasing  the  dose  to  ten  to  fifteen  drops,  is 
highly  recommended  by  Boas.  Rosenthal  recommends  subcu- 
taneous injections  of  extract  of  opium,  and  has  seen  good  results  in 
bulimia  from  cocain  hydrochlorate.  IMorphin  is  a  remedy  that  has 
been  followed  by  good  results  in  this  affection.  An  attempt  should 
be  made  with  the  use  of  electricity  in  the  treatment.  In  one  of  the 
colored  patients  to  whom  we  referred  as  champion  gluttons,  and  who 
had  subsequently  developed  bulimia,  the  symptoms  improved  ver\" 
much  under  the  intragastric  use  of  the  constant  current.  The  treat- 
ment of  acoria  should  be  mainly  that  of  neurasthenia ;  climatic 
changes  and  electrical  hydropathic  cures  are  most  effective.  Intra- 
gastric douches,  with  alternating  warm  and  cold  water,  have  been 
recommended.  It  is  very  important  that  these  patients  should  be 
watched  by  healthy  friends  during  their  eating ;  thorough  mastica- 


SYMPTOMATOLOGY  OF  NERVOUS  ANOREXIA.         8ll 

tion  and  insalivation  should  be  insisted  upon.  Strychnin  and  mas- 
sage of  the  stomach  suggest  themselves  as  rational  means  of  treat- 
ment. 

NERVOUS    ANOREXIA. 

By  anorexia  is  meant  an  entire  absence  of  appetite  and  loss  of  the 
sensation  of  hunger.  The  superlative  degree  of  this  sensation  is  ex- 
pressed in  the  disgust  and  repugnance  toward  all  food.  There  are 
probably  no  pathological  conditions,  neither  of  the  stomach  nor  of 
any  other  organ  of  the  body,  in  which  anorexia  is  not  occasionally 
met  with.  In  most  anatomical  diseases  of  the  stomach  anorexia  is 
a  regular  accompaniment.  The  separation  of  appetite  and  hunger 
is  not  so  clear  as  one  might  suppose;  the  two  are  not  necessarily 
synonymous,  nor  does  one  include  the  other.  Penzoldt  defines  hun- 
ger as  the  warning  or  admonition,  and  appetite  as  the  pleasure  of 
eating  ("Bibliothek  der  ges.  medizin.  Wissenschaften,  herausgege- 
ben  von  Drasche,"  article  on  "Anorexia").  There  may  even  be 
appetite  when  there  can  not  possibly  be  hunger.  We  have  already 
spoken  of  the  various  forms  of  anorexia  that  may  accompany  the 
organic  and  functional  diseases  of  the  stomach.  By  nervous  ano- 
rexia we  mean  loss  of  appetite,  and  even  repugnance  to  food,  that 
may  extend  over  weeks  and  months,  with  a  perfectly  intact  diges- 
tive apparatus;  this  affection  is  found  principally  in  women,  and  is 
based  upon  neurasthenia,  hysteria,  anemia,  chlorosis,  and  certain 
neuroses  of  the  stomach.  It  is  found  in  those  addicted  to  the  exces- 
sive use  of  alcohol  and  tobacco,  and  as  a  symptom  of  the  morphin 
habit.  It  is,  therefore,  not  a  disease  peculiar  to  itself,  not  a  typical 
morbid  entity,  but  rather  a  sequence.  Whether  or  not  nervous  ano- 
rexia may  be  an  independent  disease  of  central  origin,  a  neurosis  con- 
nected with  a  reduced  irritability  of  the  hunger  center,  has,  up  to  the 
present  time,  not  been  satisfactorily  investigated.  The  course  and 
the  prognosis  depend  upon  the  degree  of  the  repugnance  for  food. 
Among  the  insane  and  very  neurasthenic  patients  fatal  cases  have 
been  reported. 

Symptomatology. — The  patients  who,  from  loss  of  appetite  or 
distress,  can  not  take  food,  grow  anemic  and  weak,  appear  very  ema- 
ciated, have  a  slow,  feeble  pulse,  cold  hands  and  feet,  and  may  even 
give  the  impression  of  tuberculous  patients.  Rosenthal  ("Magen- 
neurosen,"  etc.,  Vienna  and  Leipzig,  1886),  Gull  ("The  Lancet," 
1868),  and  Charcot  ("Oeuvers  Completes,"  tome  iii,  p.  240)  have 
reported  fatal  cases  of  nervous  anorexia.     Insomnia  is  a  frequent 


8 1 2  SENSORY   NEUROSES.  . 

symptom  of  this  affection.  Very  slight  anatomical  changes  in  the 
stomach  may  cause  anorexia;  it  is,  therefore,  almost  impossible  to 
make  the  diagnosis  of  secondary  or  primary  anorexia  with  precision. 

Diagnosis. — There  is  no  difficulty  about  the  diagnosis  of  anorexia, 
but  it  is  not  always  easy  to  discover  the  real  cause  of  it.  We  will 
find  under  the  consideration  of  enteroptosis  that  almost  any  abdomi- 
nal organ  when  dislocated  may  produce  this  symptom.  Organic 
affections  of  the  stomach  must  be  excluded  before  we  can  make  the 
diagnosis  of  nervous  anorexia.  Very  frequently  chronic  gastritis, 
incipient  tuberculosis,  and  carcinoma  begin  with  this  symptom  be- 
fore any  other  signs  or  symptoms  are  manifest. 

Treatment. — The  primary  object  of  the  treatment  must  be  to 
improve  the  general  nervous  condition,  to  correct  any  existing  funda- 
mental disease,  to  act  upon  the  psychical  sphere  by  persuasion,  sug- 
gestion, and  firm  but  kind  argument,  and,  finally,  to  combat  the 
anorexia  itself  directly.  Any  existing  neurasthenia  and  hysteria 
should  be  treated  by  methods  that  have  been  spoken  of  repeatedly 
for  these  affections.  Dujardin-Beaumetz  ("Traitement  des  Mala- 
dies de  I'Estomac,"  1891,  p.  326)  speaks  very  highly  of  arsenic  in  the 
treatment  of  nervous  anorexia.  In  anemia  mild  preparations  of  iron 
(see  ferratin)  are  almost  indispensable.  The  tincture  of  the  chlorid 
of  iron  and  the  Blaud  pill  will  rarely  disagree,  and  in  those  cases  in 
which  these  forms  produce  gastric  distress  I  found  that  organic  mix- 
tures of  iron  did  so  likewise.  (See  Hemmeter,  "Absorption  of  Iron 
from  the  Gastro-intestinal  Tract,"  etc.,  "Phila.  Med.  Jour.,"  January 
13,  1900.)  It  has  been  found  that  iron  injected  subcutaneously  will 
produce  dyspeptic  distress  (Glaevecke,  "Arch.  f.  experim.  Path.  u. 
Pharm.,"  1883,  Bd.  xvii).  This  effect  of  iron  in  rare  cases  is  unavoid- 
able and  not  well  understood.  In  order  to  improve  the  general  nutri- 
tion, the  Weir  Mitchell  rest-cure, — which  consists  in  isolating  the 
patient  from  his  family  and  placing  him  under  the  supervision  of  a 
trained  nurse  and  an  experienced  physician,  and  feeding  him  so 
abundantly  that  gradually  a  gain  of  weight  is  accomplished, — 
together  with  the  use  of  baths,  massage,  and  electricity,  has,  in  many 
cases  in  our  experience,  produced  happy  results  when  other  means 
have  failed.  When  there  is  absolute  repugnance  for  food,  or  when 
the  patient  is  insane,  artificial  compulsory  alimentation  by  gavage 
should  not  be  postponed  too  long.  We  have  considered  this  fully  on 
page  192.  In  the  beginning  of  the  trouble  the  bitter  tonics  are 
available  to  stimulate  the  appetite.     The  basic  orexin,  five  to  ten 


HYPERCHYLIA.  813 

grains  three  times  a  day,  in  a  cup  of  hot  bouillon,  produces  sometimes 
excellent  results  in  these  cases  of  nervous  loss  of  appetite. 

Boas  speaks  very  highly  of  the  cinchona  bark.  It  may  be  pre- 
scribed in  the  following  formula : 

K.      Tinct.  cinchonfe  comp., 40.0  f  ^ 'ss 

Acid,  sulphuric,  dil., 10. o  f^ij 

Syr.  zingiber., q.  s.  240.0  fsvj.  M. 

SiG. — One-half  of  a  fluidounce   in   two  ounces  of  water,  through   a  glass  tube, 
three  times  a  day. 

In  some  cases  in  which  the  anorexia  was  due  to  a  feeling  of  pressure 
and  discomfort  after  eating,  Rosenthal  reports  good  results  from  ten 
to  fifteen  grains  of  bromid  of  sodium  given  before  meals.  Boas  cau- 
tions against  the  use  of  mineral  waters  in  the  treatment  of  this  neuro- 
sis. One  most  approved  combination  for  anorexia  is  given  on  page 
571;  it  contains  dilute  HCl,  because  I  have  found,  in  a  very  large 
number  of  cases  of  intense  nervous  anorexia,  that  the  gastric  secre- 
tion is  very  much  reduced  or  entirely  lost,  and  I  have  rarel}^  observed 
persistent  anorexia  together  with  normal  HCl  secretion. 


CHAPTER  XII. 
NEUROSES  OF  SECRETION. 


HYPERCHYLIA  (Hyper-  or  Superacidity;  Hyperchlorhydria). 

Most  diagnosticians  whose  clinical  and  laboratory  experience 
renders  them  competent  to  judge,  consider  hyperacidity  and  hyper- 
secretion of  the  gastric  juice  to  be  neuroses  of  the  secretory  ftmction. 
They  are  regarded  as  functional  disturbances  of  the  nerves  of  the 
stomach,  which  may  occur  as  individual  diseases  or  as  part  of  other 
neurotic  conditions.  This  view  no  doubt  is  correct  in  a  large  number 
of  the  cases.  It  includes  the  opinion  that  in  this  disease  no  char- 
acteristic changes  in  the  structure  of  the  gastric  mucous  membrane 
are  demonstrable.  Judging  from  the  results  of  Hayem,  Cohnheim, 
and  Einhorn,  and  the  author,*  it  is  beyond  a  doubt  that  in  more  than 

*Heniraeter,  "  Z.  Histologie  d.  Magendriisen  b.  Hyperaciditilt,"  "  Archiv  f.  Ver- 
dauungskrankheiten,"  Bd.  iv,  S.  23. 


8 14  NEUROSES   OF   SECRETION. 

one-half  the  cases  of  hyperacidity  examined,  proliferation  of  the  glan- 
dular elements  is  present. 

I  have  not  only  examined  fragments  of  mucosa  that  were  accident- 
ally found  in  the  wash-water,  but  have  had  opportunities  of  making 
autopsies  on  cases  of  pronounced  and  prolonged  hyperacidity  that 
died  of  intercurrent  diseases.  In  serial  sections  of  these  stomachs  it 
was  found  that  the  prevailing  state  of  the  mucosa  in  the  intermediate 
zone  and  fundus  was  that  of  glandular  proliferation,  with  increase  in 
the  number  of  oxyntic  cells.  Such  stomachs  do  not  show  the  same 
conditions  throughout.  On  making  serial  sections  of  large  pieces  of 
the  secretory  portion,  one  occasionally  meets  with  areas  in  which  the 
glandular  structure  is  apparently  normal.  At  very  rare  intervals  and 
in  rare  cases  one  can  even  find  sections  showing  partial  glandular 
atrophy.  This  is  so  rare  as  to  be  insignificant.  Even  in  normal 
stomachs  one  sometimes  finds  indications  of  atrophy  in  serial  sections, 
and  we  consider  that  these  changes  are  very  limited,  and,  perhaps, 
may  be  considered  as  processes  of  reconstruction  and  transition, 
where  accidentally  injured  or  exhausted  glands  break  down  in 
minute  foci  and  are  replaced  gradually  by  newly  formed  gland-cells. 
The  prevailing  condition,  then,  in  hyperacidity,  according  to  our 
opinion,  is  proliferation  of  the  glandular  elements  and  increase  of 
oxyntic  or  border  cells. 

A  large  number  of  microscopical  investigations  will  be  necessary  to 
confirm  this  opinion.  I  have  thus  far  examined  the  entire  stomach 
of  four  cases  that  gave  the  clinical  picture  of  hyperacidity  before 
death.  In  all  four  of  these  cases  the  proliferation  of  the  glandular 
elements  was  uniformly  present.  Strauss  has  described  conditions  in 
the  gastric  glandular  layer  which  are  confirmatory  of  my  own  results 
("Virchow's  Archiv,"  1898,  Bd.  cliv). 

Sir  William  Roberts  ("Digestion  and  Diet,"  p.  240)  holds  that  the 
acid  in  what  he  calls  acid  dyspepsia  (which  seems  to  me  an  objection- 
able term,  since  it  does  not  define  which  of  the  diseases  that  are  con- 
nected with  excess  of  acidity  he  refers  to)  is  not  unmixed  HCl,  but 
that  lactic,  butyric,  tartaric,  and  malic  acids  are  present.  These 
are  probably  derived  from  salts  of  the  organic  acids  present  in  articles 
of  food  which  are  decomposed  by  the  HCl  of  the  gastric  juice.  There 
may,  of  course,  be  a  hyperacidity  due  to  excess  of  organic  acids,  which 
may  present  all  the  symptoms  of  hyperchlorhydria ;  in  such  cases 
there  is,  in  my  experience,  no  HCl  secreted  at  all.  What  I  refer  to 
clinically  as  hyperacidity,  however,  is  an  excessive  formation  of  hy- 


RELATION    OF    ACIDITY    OF    URINE   AND    GASTRIC    ACIDITY.       815 

drochloric  acid  from  the  gastric  glands.  Concerning  the  nature  and 
origin  of  this  acid  we  have  nothing  but  theories. 

It  has  been  suggested  that  the  hyperchlorhydria  is  due  to  an  excess 
of  chlorids  in  the  organisms,  from  which  it  Hberates  itseh  b}^  excre- 
tion into  an  organ  where  the  freeing  of  the  system  from  chlorids  could 
at  the  same  time  become  of  utility  as  a  digestive  secretion  in  the  form 
of  HCI.  The  author  has  made  a  number  of  experiments  by  feeding 
carnivorous  animals  with  food  from  which  the  chlorids  had  been 
removed  so  far  as  w^as  possible.  The  acidity  of  the  gastric  juice  of 
the  dog  will  become  very  much  reduced  if  the  chlorids  are  withdrawn 
from  the  food.  This,  however,  is  no  proof  of  the  supposition  that  the 
reduction  of  chlorids  is  the  cause  of  the  diminished  secretion  of  HCI, 
because  foods  containing  considerable  of  chlorids  are  a  healthy  stimu- 
lant to  the  normal  secretion  of  HCI,  and  food  deprived  of  chlorids  can 
not  exert  this  stimulation  upon  the  mucosa.  Personally,  the  author 
considers  it  very  probable  that  hyperacidity  is  frequently  an  adaptire 
process :  that  is  to  say,  the  glandular  layer  gradually  develops  greater 
secretory  powers,  because  more  secretion  of  HCI  is  required  by  the 
nature  of  the  ingested  food.  We  have  been  told  by  two  physicians 
practising  in  Japan  that  hyperacidity,  as  well  as  gastric  ulcer,  are 
practically  unknown  in  that  country,  which  may  be  partially  ex- 
plained by  the  exclusive  carbohydrate  diet  upon  which  the  middle 
and  lower  classes  of  that  nation  exist. 

It  is  a  well-known  fact  that  the  gastric  juice  of  carnivora  contains 
relatively  more  HCI  than  that  of  the  herbivora.  It  may  not  be  so 
well  known  that  the  gastric  juice  of  a  carnivorous  animal  can  be  made 
to  contain  a  less  amount  of  HCI  by  being  fed  upon  a  carbohydrate 
diet  for  a  long  time.  Two  dogs  of  the  same  litter,  (a),  fed  exclusively 
on  milk,  potatoes,  and  rye  bread,  and  (fc),  fed  exclusively  on  beef, 
mutton,  pork,  fish,  and  water:  At  the  end  of  one  year  dog  (a),  fed 
upon  carbohydrates,  had  a  gastric  juice  one  hour  after  a  roll  and  a 
half  pint  of  water,  containing  3  per  1000  of  HCI ;  dog  (b),  who  was  fed 
upon  a  meat  diet,  had  a  gastric  juice  containing  6.540  per  1000  HCI 
after  the  same  test-meal.  The  figures  are  the  results  of  the  average  of 
ten  different  analyses  on  each  dog.  These  two  dogs  were  raised  in 
two  entirely  different  families.  Dog  (a)  was  raised  by  a  gentleman 
living  in  a  country  district  where  meat  was  not  easily  obtained  and 
milk  was  very  abundant;  dog  (6)  was  raised  in  the  city,  and  lived 
upon  the  refuse  meats  from  the  table.  Since  the  publication  of  the 
first  edition  these  two  fox  terriers  have  been  kept  in  the  same  faniilits 


8l6  NEUROSES   OF   SECRETION. 

and  two  other  terriers  have  been  raised  in  the  same  way.  The  results 
of  test-meals  show  that  the  gastric  juice  of  the  dogs  raised  on  meat 
contains  twice  as  much  HCl  on  the  average  (6.6320  per  1000)  as  that 
of  the  dogs  fed  on  milk,  bread,  and  potatoes.  Unless  conducted  in 
this  manner,  and  watched  by  competent  observers  for  a  long  time, — 
at  least  one  year, — the  experiment  is  of  no  practical  utility.  It  is 
conceivable  that  we  do  not  as  yet  know  all  of  the  constituents  of  the 
gastric  juice ;  clinically,  it  has  been  very  frequently  observed  that  the 
secretions  of  the  intestines  may  contain  traces  of  products  of  meta- 
bolism and  other  toxins,  when  the  function  of  the  kidney  is  suppressed 
or  lost.  The  gastric  juice  of  epileptics  may  contain  toxic  substances. 
Augustini,  who  recently  investigated  this  subject,  found  that  the 
gastric  juice  of  an  epileptic,  when  injected  into  the  abdomen  of  a  rab- 
bit, proved  fatal,  with  general  toxic  symptoms  and  clonic  convulsions. 
This  was  especially  true  when  the  gastric  juice  was  obtained  imme- 
diately before  or  after  an  attack.  Normal  gastric  juice  was  found  to 
produce  no  such  evil  effects.  The  probable  action  of  bacteria  can  not 
be  excluded  from  these  experiments.  Augustini  concludes  from  these 
experiments  that  systematic  lavage  and  disinfection  of  the  stomach 
and  intestines  are  indicated  in  all  cases  of  epilepsy.  What  we  wish 
to  emphasize  in  this  introduction  to  the  consideration  of  hyperacidity 
is  that  hyperchlorhydria,  although  frequently  a  neurosis,  is,  in  our 
opinion,  very  often  a  process  of  adaptation  of  the  mucosa  to  the  de- 
mand for  increased  work. 

Acidity  of  the  Urine  and  Gastric  Contents  in  the  Healthy  and 
in  the  Dyspeptic. — Mathieu  and  Treheux  ("Arch.  Gen.  de  Med.," 
November,  1895)  have  made  researches  on  this  subject.  They  ex- 
amined the  urine  hourly  during  the  afternoon,  after  the  midday  meal, 
carrying  out  their  investigations  on  twelve  persons,  after  eighty -four 
different  meals,  thus  making  over  400  estimates  of  the  degree  of  acid- 
ity of  the  gastric  contents  and  urine.  The  individuals  examined  were 
the  subjects  of  hyperchlorhydria,  with  and  without  symptoms  of  gas- 
tric dilation,  carcinoma,  etc.  The  authors  conclude  that :  (i)  There 
is  a  relation  between  the  acidity  of  the  gastric  contents  and  the  urine. 
(2)  The  greater  the  production  of  acid,  whether  by  secretion  or  fer- 
mentation, the  greater  the  amount  of  acid  excretion  in  the  urine.  (3) 
Normally,  the  acidity  of  the  urine  falls  during  the  first  three  to  five 
hours  after  eating;  thereafter  it  increases.  (4)  Most  often  there  is 
an  almost  absolute  parallelism  between  the  two  curves  of  gastric  and 
urinary  acidity,  but  this  is  destroyed  after  a  repast  by  the  presence 


HISTORY    OF    SUPERACIDITY.  817  • 

of  polyuria.  (5)  If  the  acid  is  withdrawn  by  any  means  from  the 
stomach,  the  amount  in  the  urine  falls  also,  and  the  latter  may  even 
become  alkaline.  (6)  The  average  quantity  eliminated  by  the  urine 
hourly  is  greater  in  hypochlorhydria  (subacidity)  than  in  h^'per- 
chlorhydria  (superacidity).  (7)  Milk  increases  the  acid  in  the 
urine,  owing  to  its  giving  rise  to  lactic  acid  in  the  stomach.  (8)  It 
is  not  possible,  at  any  rate  at  present,  to  trace  the  curves  of  urinary 
acidity  so  as  to  bear  indirectly  on  the  question  of  the  chemical  va- 
riety of  the  dyspepsia.  (9)  Milk  must  be  excluded  from  test-meals 
w^hen  these  curves  are  to  be  studied.  (10)  Patients  should  be 
subjected  to  a  constant  regimen  for  some  time  before  the  investi- 
gations. 

Nature  and  Concept. — As  the  name  implies,  the  factor  with  which 
we  are  most  particularly  concerned  in  this  neurosis  is  the  HCl.  With 
superacidity,  a  gastric  juice  unusually  rich  in  HCl  and  pepsin  is  se- 
creted in  very  large  quantities  during  digestion,  as  a  result  of  the 
stimulation  of  the  foods.  On  this  account  free  HCl  may  be  proved 
in  the  stomach  after  test-meals  much  earlier  than  under  normal  cir- 
cumstances, and  the  acidity  of  the  digestive  mixture  is  further  in- 
creased as  digestion  proceeds.  Superacidity  may  be  an  independent 
disease  confined  to  the  stomach  alone,  or  a  partial  symptom  of  hys- 
teria, neurasthenia,  and  melancholia.  It  may  also  be  noticed  as  a 
reflex  neurosis  with  renal  calculus  and  hepatic  colic,  and  as  the  com- 
panion of  organic  changes  of  the  stomach  (ulcus  ventriculi,  gastritis 
acid  a) . 

His.torical. — Even  if  superacidity,  like  supersecretion,  has  been 
demonstrated  with  certainty  only  in  the  last  twelve  years,  through 
the  researches  of  Reichmann,  Jaworski,  van  den  Velden,  Riegel,  the 
latter's  pupils,  and  others,  and  the  aspect  of  the  disease  has  been 
precisely  defined  by  them,  nevertheless,  as  Ewald  justly  emphasizes, 
it  would  be  an  error  to  believe  that  we  have  to  do  with  an  entirely 
new  discovery,  since  both  these  anomalies  of  secretion,  as  also  their 
nervous  origin,  were  known  to  older  physicians  in  the  beginning  and 
middle  of  this  century — men  celebrated  in  England,  France,  and 
Germany  (Trousseau,  Todd,  Budd,  Copland,  Pemberton,  Hiibner, 
and  others).  By  some  of  these,  the  most  important  symptoms  were 
also  correctly  stated.  It  is  not  intended  that  the  merit  of  the  pre- 
viously mentioned  investigators  of  these  neuroses  of  secretion  shall 
be  in  any  way  diminished  by  this  older  historical  reminiscence,  for  as 
the  older  ph^-sicians,  owing  to  the  lack  of  exact  methods,  could  not 


8l8  NEUROSES   OF   SECRETION. 

recognize  those  anomalies  of  secretion  with  certainty,  their  results 
were  soon  forgotten ;  Reichmann  was  the  first  who,  by  a  thorough  ex- 
amination of  the  contents  of  the  stomach,  with  the  help  of  newer  and 
constantly  improving  methods,  furnished  certain  proof  of  the  exist- 
ence of  secretory  disorders  which  had  previously  been  only  suspected, 
while  it  was  Ewald  especially  who  emphasized  particularly  the  ner- 
vous origin  of  supersecretion  and  superacidity,  so  that  soon  they  were 
generally  recognized  as  neuroses.  The  observations  of  Reichmann 
were  soon  after  confirmed  by  von  Noorden,  Honigmann,  Riegel,  Ja- 
worski,  Saly,  and  others,  and  to-day  there  is  a  consensus  of  opinion 
concerning  the  nature  and  consequences  of  both  neuroses.  Jaworski 
designates  both  neuroses  as  very  frequent  disorders,  since  he  could 
prove  them  in  almost  two-thirds  of  his  patients  who  had  diseases  of 
the  stomach,  while  Riegel  also  observed  them  very  frequently  in 
Hessia, — although  not  quite  so  frequently  as  Jaworski.  Kwald, 
with  whom  the  author  can  agree,  states  that  they,  especially  super- 
secretion,  occurred  only  in  a  fraction  of  his  patients  with  diseases  of 
the  stomach,  so  that  supersecretion  should  be  called  rare,  rather  than 
frequent. 

Etiology. — The  fundamental  causes  of  superacidity  are  still  un- 
known. The  little  that  has  up  to  date  become  known  concerning  the 
etiology  of  the  disease  is  confined  to  the  knowledge  of  a  few  predis- 
posing factors.  Very  excitable  people,  predisposed  to  nervous  dis- 
orders, more  frequently  become  affected  with  superacidity  than  those 
of  calm  temperament,  who  do  not  lose  their  equanimity  so  easily, 
although  it  is  not  found  entirely  wanting  in  the  latter.  Jaworski 
found  hyperacidity  very  frequently  in  the  excitable  Jewish  population 
of  Galicia,  preeminently  disposed  to  nervous  disorders.  With  hys- 
terical patients  superacidity  was  noticed  by  Jolly,  and  in  melan- 
cholic subjects  by  von  Noorden,  and  it  is  also  a  frequent  companion 
to  neurasthenia.  The  disease  is  more  common  in  men  than  in  women. 
The  educated,  and  particularly  the  learned,  classes  furnish  the  main 
body  of  patients  suffering  from  superacidity,  though  it  is  not  infre- 
quent in  the  laboring  classes.  Local  causes  seem  to  play  an  impor- 
tant role  in  the  etiology  of  superacidity,  and  this  is  vouched  for  by 
the  frequent  occurrence  of  the  disease  in  Galicia  and  Hessia  (Riegel), 
while  it  is  much  rarer  in  other  districts.  It  would  be  a  valuable  con- 
tribution by  various  gastro-enterologists  of  the  United  States  if  they 
collected  and  reported  the  frequency  of  hyperacidity  and  other  gas- 
tric diseases  occurring  in  their  localities,  so  as  to  throw  light  on  the 


SYMPTOMATOLOGY   OF   SUPER  ACIDITY.  819 

influences  of  race,  climate,  geographical  distribution,  etc.  It  is  my 
opinion  that  a  diet  rich  in  fish,  meats,  and  proteids  in  general  pre- 
dispose to  hyperacidity.  That  the  frequent  occurrence  of  superacid- 
ity  with  cholelithiasis  and  nephrolithiasis  is  a  causal  relation  and  not 
a  mere  accidental  coincidence  is  shown  by  the  fact  that  the  stomach 
complaints  dependent  on  superacidity  generally  disappear  quickly 
after  the  passage  of  the  calculi  into  the  intestines  and  bladder  respec- 
tively. The  relation  between  superacidity  and  peptic  ulcer  has  been 
suflficiently  dwelt  upon  in  the  discussion  of  the  pathogenesis  of  the 
latter ;  whether  superacidity  is  a  cause  or  result  of  the  ulcer,  it  has, 
up  to  date,  been  impossible  to  decide  with  certainty.  In  the  first 
half  of  this  work  the  author  has  laid  down  reasons  why  hyperacidity 
may  in  some  instances  be  sufficiently  explained  by  the  proliferation  of 
glandular  elements  observed  in  fragments  of  mucosa  found  in  the 
wash-water  in  one-half  to  two-thirds  of  the  cases  of  hyperacidity 
examined  (Hemmeter,  "Experimental  Basis  of  the  Dietetic  and 
Medicinal  Treatment  of  Hyperacidity,"  etc.,  "Jour.  Amer.  Med. 
Asso.,"  Oct.  9,  1897).  Whether  this  condition  is  the  cause  or  the 
result  of  the  neurasthenia  is  difficult  to  determine,  though  we  ob- 
served it  when  no  neurasthenia  could  be  detected. 

Symptomatology. — Disturbances  of  Sensibility. — ^The  subjective 
complaints  consist  chiefly  in  contracting,  boring,  burning,  or  gnaw- 
ing pains  in  the  entire  region  of  the  stomach,  which  generally  radiate 
forward  or  toward  the  back.  As  they  are  the  consequences  of  a 
strong  irritation  of  the  mucous  membrane  of  the  stomach  by  its 
superacid  contents,  they  are  generally  noticed  only  during  digestion, 
appearing  some  time  after  eating,  and  generally  increasing  perceptibly 
with  the  progress  of  digestion.  They  are  much  influenced  by  the 
quantity  and  composition  of  the  food;  with  meats  they  are  in  some 
patients  less  perceptible  than  with  an  amylaceous  diet.  After  the 
introduction  of  food  very  rich  in  albumin  they  appear  later  than  with 
a  diet  poor  in  albuminates,  mainly  because  in  the  former  case  the  ap- 
pearance of  free  HCl  in  the  contents  of  the  stomach  is  postponed 
because  the  first  HCl  that  is  secreted  combines  with  the  albumen. 
At  the  height  of  digestion  the  symptoms  are  generall}^  most  severe. 
Temporary,  strong,  cramp-like  pains  in  the  region  of  the  pylorus  are 
generally  the  result  of  a  spasm  of  the  muscular  sphincter  of  the 
pylorus.  By  alkalies,  as  also  by  the  renewed  taking  of  milk,  eggs,  or 
meat,  the  painful  sensations  are  generally  soon  alleviated  or  tem- 
porarily done  away  with,  so  long  as  the 'acid  is  held  in  combination  by 
54 


820  NEUROSES   OF   SECRETION. 

the  alkalies  or  albuminates.  If  a  strong  generation  and  collection 
of  gases  occur,  the  region  of  the  stomach  is  swollen,  and  in  some 
degree  sensitive  to  touch.  If  the  escape  of  the  gases  upward  or  down- 
ward is  temporarily  prevented  by  simultaneous  cramp  of  the  cardia 
and  pylorus,  the  complaints  are  considerably  increased,  owing  to  the 
strong  expansion  of  the  walls  of  the  stomach.  Other  gastric  symp- 
toms, such  as  nausea,  belching,  and  vomiting  of  very  acid  masses 
accompany  hyperchylia  very  frequently.  Belching  effects  slight, 
passing  relief,  while  copious  vomiting  brings  greater  and  more  lasting 
relief.  If  small  quantities  of  the  very  acid  contents  of  the  stomach 
are  brought  up  through  the  eructations,  and  if  the  mucous  mem- 
brane of  the  esophagus  is  subjected  to  caustic  action  by  the  latter, 
heartburn  develops,  which  may  increase  to  a  severe  contracting  pain 
under  the  sternum,  which  extends  to  the  pharynx  (pyrosis  hydro- 
chlorica,  Sticker).  The  same  complaints,  naturally,  may  also  ap- 
pear after  the  vomiting  of  the  contents  of  a  very  acid  stomach.  The 
manifold  subjective  symptoms  previously  stated  are  sometimes  also 
observed  with  neurasthenic  patients  in  whom  the  acidity  of  the  gas- 
tric juice  is  normal.  An  abnormal  sensibility  of  the  gastric  nerves 
to  hydrochloric  acid  must  be  supposed  in  these  cases  (Talma).  The 
appetite  is  generally  undisturbed  in  patients  afflicted  with  super- 
acidity;  occasionally,  it  is  even  increased.  Thirst  is  often  much 
increased. 

The  Influence  of  Hyperchylia  upon  the  Transformation  of  the  Foods 
in  the  Stomach. — As  is  well  known,  with  increasing  acidity  of  the 
gastric  juice  (at  least,  up  to  a  certain  limit)  its  digestive  power  for 
albuminous  foods  is  increased,  and  peptonization  proceeds  more 
quickly  and  freely  the  sooner  free  hydrochloric  acid  is  present  in  the 
contents  of  the  stomach.  Both  conditions  are  given  with  patients 
suffering  from  hyperacidity.  The  acidity  of  the  gastric  juice  is  much 
greater  than  that  of  the  normal  secretion,  which  amounts  to  0.15  to 
0.2  per  cent.  It  varies  between  0.3  and  0.6  per  cent,  in  hyperchylia; 
in  severe  cases  between  0.4  and  0.6  per  cent.,  so  that  in  these  80  to 
120  c.c.  of  a  decinormal  solution  of  sodium  hydroxid  are  necessary  to 
neutralize  100  c.c.  of  the  gastric  contents  drawn  at  the  height  of  the 
digestion  of  a  test-meal.  Free  HCl  may  be  shown  in  the  contents  of 
the  stomach  in  ten  minutes  after  a  test-breakfast,  instead  of  in  an 
hour,  and  in  one  hour,  instead  of  in  three  to  four  hours,  after  the  full 
test-dinner;  therefore,  the  peptonization  of  albumin  proceeds  in  a 
very  prompt  and  free  manner.     On  the  other  hand,  gastric  amylolysis 


THE   EFFECT   ON   THE   MOTOR  FUNCTION.  82 1 

is  somewhat  retarded,  as  the  effectiveness  of  the  ptyahn  is  interrupted 
very  early  by  the  appearance  of  free  HCl.  On  this  account  one  finds, 
in  three  to  four  hours  after  an  experimental  meal,  no  undigested  mus- 
cular fibers  and  albuminous  particles  in  the  contents  of  the  stomach ; 
but  many  unchanged  amylaceous  particles  may  still  be  found  in  the 
residue  on  the  filter.  (This  is  best  studied  with  the  double  test-meal, 
as  recommended  on  pp.  123,  124.) 

If  the  acidity  of  the  gastric  juice  exceeds  a  certain  maximum  (0.6 
to  0.7  per  cent,  and  over),  even  the  digestion  of  the  albumin  is  in  some 
way  retarded  (Schwann),  due,  in  my  opinion,  to  an  unusually  large 
amount  of  peptone  present.  Ferments  do  not  act  readily  in  the 
presence  of  an  excess  of  their  products.  But  up  to  the  present  time 
such  great  quantities  of  free  HCl  have  not  been  met  with  in  the  con- 
tents of  the  stomachs  of  patients  suffering  from  hyperacidity. 

A  copious  formation  and  collection  of  gases  may  occur  in  this  neu- 
rosis of  secretion. 

The  Effect  on  the  Motor  Function. — With  very  severe  irritation 
of  the  mucous  membrane  of  the  stomach  by  the  overacid  contents, 
abnormally  severe  contractions  of  the  musculature  are  produced 
reflexly,  by  which  a  quicker  flow  of  blood  to  and  from  the  gastric 
walls  is  effected.  A  more  intimate  contact  of  the  ingesta  with  the 
mucous  membrane  of  stomach  hastens  secretion  as  well  as  the  diges- 
tion and  resorption  of  the  albuminates,  and  also  the  passing  over  of 
the  chyme  into  the  intestines.  Therefore,  one  should  expect  a  quick- 
ened emptying  of  the  stomach  in  patients  with  hyperacidity ;  but  in 
many  cases  exactly  the  opposite  is  noted — namely,  a  retarded  pas- 
sage of  the  contents  of  the  stomach  into  the  intestines.  It  is  gen- 
erally caused  by  a  stubborn,  often-recurring  cramp  of  the  pylorus, 
brought  about  by  the  strong  irritation  of  the  mucous  membrane  of  the 
pylorus  by  HCl,  which  even  the  most  extreme  contractions  of  the 
rest  of  the  musculature  can  not  overcome.  These  overexertions  of 
the  latter  may  lead  to  fatigue  and  to  atony,  and  the  appearance  of 
this  state  is  furthered  by  the  fact  that  the  coats  of  the  stomach  are 
burdened  and  distended  by  the  ingesta  more  than  under  normal  cir- 
cumstances. Since,  however,  the  musculature  can  rest  and  recuper- 
ate with  an  empty  stomach,  the  atony  does  not  very  frequently 
pass  over  into  a  chronic  state  of  dilation  of  the  stomach.  The 
formation  of  the  dilation  is,  however,  to  be  feared  when  the  cramp 
of  the  pylorus  brings  about  a  hypertrophy  of  its  ring  muscles,  and 
with  it  a  stenosis  of  its  lumen.     The  disturbances  of  circulation  in 


822  NEUROSES   OF   SECRETION. 

the  coats  of  the  stomach,  caused  by  the  cramp  of  the  pylorus,  in 
the  presence  of  a  very  acid  and  potent  gastric  juice  may  favor  the 
formation  of  peptic  ulcer.  The  troublesome  thirst  so  often  com- 
plained of  by  patients  was  formerly  explained  by  a  reduction  of  the 
power  of  resorption  of  the  mucous  membrane,  caused  by  the  strong 
irritation  of  the  same  (HCl)  and  the  spasm  of  the  smaller  vessels. 
The  quick  cessation  of  thirst  after  copious  drafts  of  water  has  been 
explained  by  the  dilution  of  the  acid  chyme  and  a  decrease  of  the 
irritation  of  the  mucous  membrane. 

That  superacidity  may  cause  disturbance  of  resorption  is  not  to  be 
denied.  Since  it  is  known,  however,  that  the  greater  part  of  the 
water  introduced  is  absorbed  only  in  the  intestine,  and  that  the  resorp- 
tion of  water  in  the  normal  stomach  is  only  very  slight,  it  might  be 
more  correct  to  trace  back  the  thirst  with  superacidity  to  the  cramp 
of  the  pylorus  and  the  longer  retention  of  the  water  in  the  stomach. 
After  copious  drinking  of  water,  with  dilution  of  the  contents  of  the 
stomach,  the  irritation  of  the  mucous  membrane  of  the  pylorus  de- 
creases, the  cramp  is  lessened,  and  the  water,  passing  into  the  small 
intestine,  is  then  quickly  absorbed  in  the  latter.  That,  indeed,  a 
cramp  of  the  pylorus  with  hyperacidity  often  causes  retention  of  the 
contents  of  the  stomach  may  be  proved  by  the  introduction  of  the 
tube  before  and  after  taking  the  water — especially  when  it  contains 
alkalies  (Saratoga  Vichy) .  Before  the  taking  of  water  the  contents 
of  the  stomach  still  show  abundance  of  food ;  while  some  time  after, 
the  stomach  is  generally  found  to  be  entirely  empty. 

Urine. — After  copious  vomiting,  by  which  a  part  of  the  HCl  is 
permanently  removed  from  the  organism,  the  urine  has  an  alkaline 
or  neutral  reaction  (Sticker,  Gluzinski,  Jaworski,  and  Hiibner) ;  but 
this  may  be  observed  during  the  digestion  in  the  stomach  without 
vomiting.  Since  the  phosphates  more  easily  separate  out  of  the  alka- 
line urine,  it  may  happen  that  the  urine  is  turbid  or  milk-like  when 
voided,  a  circumstance  sometimes  unnecessarily  alarming  the  pa- 
tient ;  or,  after  standing  a  while,  the  urine  ma}^  show  a  very  plentiful 
sediment.     The  chlorids  are  sometimes  decreased. 

The  state  of  nutrition  generally  remains  good,  especially  at  first. 
If  considerable  disturbance  of  the  motility  appears,  the  nutrition 
becomes  impaired. 

The  Digestion  of  the  Foods  in  the  Intestine. — If  the  contents  of  the 
stomach  enter  the  intestine  in  an  overacid  condition,  it  requires  much 
more  than  the  usual  time  to  attain  the  alkaline  reaction  in  the  con- 


DIFFERENTIATION   OF   HYPERACIDITY   FROM   ULCER.  823 

tents  of  the  intestines  with  the  help  of  the  mixed  alkaline  intestinal 
juices.  An  alkaline  medium  is  the  most  favorable  for  the  digestion 
of  fats  and  carbohydrates. 

In  the  period  immediately  succeeding  the  passage  of  the  chyme 
into  the  small  intestine,  so  long  as  there  is  still  free  HCl  present,  a 
small  part  of  the  undigested  albumin  is  peptonized  by  the  pepsin 
which  has  passed  over  along  with  it,  while,  on  the  other  hand,  the 
transformation  of  the  carbohydrates  and  fats  is  arrested  in  this  time. 
Consequently,  the  digestion  and  assimilation  of  the  foods  in  the  intes- 
tine are  much  retarded  in  severe  cases  of  hyperacidity,  and  the 
evacuation  of  the  bowels  is  correspondingly  dela)^ed.  The  very  acid 
chyme  occasionall}^  produces  an  abnormally  intense  peristalsis  of  the 
intestine,  so  that  in  exceptional  cases  the  evacuation  of  the  intestines 
may  be  diarrheic  in  character. 

Prognosis. — This  is  favorable  if  the  disease  is  of  recent  origin; 
older  cases,  however,  are  often  stubborn.  The  ever-recurring  pains 
and  disturbances  of  digestion  may,  in  the  course  of  time,  exhaust 
the  patient.  With  symptomatic  superacidity  the  prognosis  must  be 
made  in  accordance  with  that  of  the  primary  complaints.  If  these — 
e.  g.,  hysteria,  neurasthenia,  melancholia,  peptic  ulcer,  or  cholelithia- 
sis and  nephrolithiasis — are  successfully  relieved,  the  superacidity 
will  quickly  disappear.  In  the  author's  experience  permanent  relief 
may  follow  persistent  treatment,  even  in  chronic  cases. 

Diagnosis. — In  this  disease  our  double  test-meal  (see  p.  124)  is 
a  special  diagnostic  aid.  If  a  strong  reaction  for  HCl  is  shown  in  the 
contents  of  the  stomach  after  ten  to  twenty  minutes  succeeding  the 
test-breakfast,  or  in  one  to  one  and  one-half  hours  after  the  test- 
dinner,  and  if  the  macroscopic  and  microscopic  examinations  in  the 
residue  on  the  filter  still  show  abundant  remnants  of  carbohydrates, 
with  complete  absence  of  muscular  fibers  and  particles  of  albumin, 
then  the  diagnosis  of  hyperacidity  is  established,  even  though  the 
other  previously  mentioned  symptoms  may  be  absent.  In  order  to 
prove  or  disprove  a  coexistent  supersecretion,  we  recommend  to  let 
the  patient  take  the  test-meal  at  night,  and  the  next  morning  intro- 
duce the  tube  before  breakfast.  If  it  contains  large  quantities  (over 
100  c.c.)  of  a  potent  secretion,  then  supersecretion  exists  side  by  side 
with  superacidity;  and  if  the  stomach  be  empty,  or  if  only  a  small 
quantity  of  gastric  juice  be  found  in  it,  then  supersecretion  is  not 
present.  The  result  is  still  more  certain  if  a  few  hours  after  the  last 
evening  meal  the  stomach  is  thoroughly  washed  out  and  the  tube  is 


824  NEJUROSKS   OF   SECRETION. 

introduced  into  the  jejune  stomach  the  next  morning.     Schreiber  as- 
serts that  supersecretion  is  found  only  in  atonic  stomachs. 

The  differential  diagnosis  between  the  ulcer  and  hyperacidity  is  of 
practical  importance  on  account  of  the  therapeutics  to  be  followed. 
With  both  diseases  the  manifold  subjective  complaints  appear  usually 
after  eating;  with  peptic  ulcer  patients,  generally  very  soon  after 
eating ;  with  those  suffering  from  hyperacidity,  later  on  at  the  height 
of  digestion,  though  the  onset  varies  considerably  according  to  the 
quantity  and  character  of  the  foods. 

In  gastric  ulcer  the  pains  are  generally  confined  to  one  region, — 
namely,  the  epigastrium  (circumscribed  pain  caused  by  pressure), — 
and  they  very  often  radiate  forward,  laterally,  toward  the  loins  and 
shoulder-blades  (dorsal  pain-points),  while  in  the  case  of  superacidity 
a  diffused  sensation  of  pain  exists  in  the  whole  region  of  the  stomach 
and  the  radiating  pains  are  wanting,  and  also  the  dorsal  pain-points, 
which,  in  the  case  of  ulcer,  will  be  present  in  about  one-third  of  the 
cases. 

In  the  case  of  ulcer  the  pains  are  generally  strongest  when  food  in 
itself  difficult  of  digestion  has  been  introduced  in  large  quantities, 
and  it  is  irrelevant  in  this  case  if  the  food  consisted  mainly  of  carbo- 
hydrates or  meats ;  in  the  case  of  hyperacidity  the  pains  are  generally 
less  severe  after  abundant  meals,  even  if  the  latter  consisted  of  foods 
in  themselves  difficult  of  digestion,  provided  only  that  they  are  rich  in 
albumin;  after  smaller  meals  with  little  albumin  the  pains  are  not 
relieved,  for  it  is  the  albumin  or  proteid  of  the  food  which  alone  has 
binding  affinity  for  the  excess  of  HCl. 

If  the  symptoms  observed  in  the  patient  do  not  suffice  to  establish 
a  positive  differential  diagnosis  between  ulcer  and  hyperacidity,  it  is 
safer  to  treat  the  patient  for  ulcer — this  may  be  the  case  when  it  is 
impossible  to  pass  the  tube  on  account  of  suspected  ulcer.  If  the 
pains  become  less  or  cease  entirely  soon  after  beginning  this  treat- 
ment, it  is  probably  a  case  of  ulcer,  while  if  they  remain  the  same  or 
increase,  it  is  a  case  of  hyperacidity.  If  the  hyperacidity  is  removed 
by  this  treatment  at  the  same  time  as  the  ulcer,  this  fact  suggests 
that  the  hyperchylia  was  not  the  cause,  but  the  result,  of  ulcer.  On 
the  other  hand,  if,  after  curing  the  ulcer,  the  hyperchylia  continues, 
we  may  presume  either  an  accidental  coincidence  of  the  two,  or  else 
the  hyperacidity  has  caused  the  ulcer.  In  the  latter  case  the  break- 
ing out  of  the  ulcer  or  the  formation  of  new  ulcers  is  to  be  feared  in  the 
future  should  the  hyperacidity  continue. 


DIET   IN    HYPERACIDITY.  825 

Concerning  the  terminology  of  this  and  allied  diseases  it  is  neces- 
sary to  emphasize  that  the  term  "chylia"  refers  to  the  gastric  juice 
as  a  whole, — i.  e.,  including  HCl,  pepsin,  and  chymosin, — but  the 
word  "acidity,"  of  course,  can  not  include  these  ferments.  As  the 
HCl  is  the  principal  constituent  which  is  increased,  and  though  the 
ferments  are  more  active,  there  is  no  evidence  proving  that  the}^  are 
proportionately  increased  with  the  acid  HCl  in  simple  hyperacidity 
or,  as  it  is  also  called,  superacidity — I  consider  the  latter  term  pref- 
erable to  the  word  "hyper chylia." 

Therapeutics. — (a)  Diet. — The  selection  of  proper  diet  for  these 
cases  is  one  of  the  most  important  duties  of  the  general  practitioner 
and  specialist.  There  are  two  systems  of  dietetic  treatment  for 
hyperacidity.  One  favors  the  use  of  amylaceous  diet  and  the  re- 
striction of  proteids,  because  the  latter  are  powerful  stimulants  to 
HCl  secretion.  The  advocates  of  the  other  argue  that,  since  the  man- 
ifold complaints  with  hyperchylia  are  a  result  of  the  irritation  of  the 
nerves  of  the  stomach  by  free  HCl,  therefore,  in  the  fixing  of  a  rational 
diet  such  foods  must  be  chosen  which  combine  with  the  greatest 
quantity  of  HCl — that  is,  in  the  first  place,  meats;  in  the  second, 
vegetables'  especially  rich  in  proteid.  All  the  stimulants  which 
might  further  increase  the  irritation  of  the  nerves  of  the  stomach 
must  be  avoided — viz.,  pungent  spices,  tapioca,  pepper,  also  mustard, 
horseradish,  ginger,  organic  acids,  such  as  lactic,  acetic,  citric,  and 
tartaric  acids,  fatty  acids  (rancid  fat) ;  table  salt  must,  so  far  as  pos- 
sible, be  kept  out  of  the  stomach ;  drinks  rich  in  alcohol  are  injurious 
— ^strong  beer,  heavy  wines,  but  especially  whisky  and  cognac.  Food 
and  drink  must  not  be  taken  too  cold  (not  under  8°  to  10°  R. — 10°  to 
12.5°  C.)  and  not  too  hot  (not  over  45°  R.  or  56°  C).  After  foods  in 
themselves  difficult  of  digestion,  the  complaints  are  not  increased, 
provided  they  contain  much  albumin,  than  after  easily  digestible 
ones ;  nevertheless  the  latter  are  to  be  preferred,  and  careful  prepara- 
tion is  requisite  in  order  to  avoid  a  mechanical  irritation  of  the  nerves 
of  secretion.  A  diet  consisting  only  of  carbohydrates  is,  in  our  ex- 
perience, not  injurious.  I  have  exhaustively  stated  the  advisability 
of  amylaceous  diet  in  hyperacidity  on  pages  197  to  199.  Pure  fats 
are  allowed  in  the  same  quantities  as  in  the  case  of  healthy  people. 
H.  Strauss  and  T.  Aldor  have  given  the  experimental  evidence  that 
fats  are  digested  as  well  in  hyperacidity  as  in  subacidity  ("Zeitschr. 
f.  diat.  u.  physik.  Thcrap.,"  Bd.  i,  vS.  134).  Fats  and  oils  have  a  ten- 
dency to  diminish  the  HCl  secretion  (Pawlow,  /.  c),  and  therefore 


826  NEUROSES   OF  SECRETION. 

have  a  therapeutic  value.  As  sugar  does  no  harm  in  the  case  of 
most  patients,  such  baked  foods  (cakes)  are  to  be  permitted  in  which, 
by  a  long  process  of  baking  or  roasting,  a  part  of  the  starch  has  been 
dextrinized :  that  is,  well-toasted  bread,  cakes,  breadcrust  soaked  in 
milk,  and  also  certain  dextrinized  flours  (Horlick's  food,  Kufeke's 
flour,  and  others).*  On  account  of  frequent  disturbance  of  the  mo- 
tility large  quantities  of  water,  by  which  the  muscularis  of  the  stom- 
ach is  unusually  distended,  must  not  be  introduced  at  one  time ;  it  is 
much  better  to  give  small  quantities  frequently,  by  which  at  the  same 
time  the  acid  contents  of  the  stomach  are  diluted.  Burning  thirst  is 
best  quenched  by  frequent  imbibing  of  small  quantities  of  alkaline 
mineral  waters  (vSaratoga  Vichy,  Geyser,  Capon  Springs,  ApoUinaris 
water,  Selters,  Geisshiibler,  Fachinger  water),  which  are  rich  in  alka- 
lies and  carbonic  acid  gas.  The  latter  is  not  only  soothing,  but  also 
favors  resorption. 

Since  the  percentage  of  albumin  of  the  various  foods,  and  hence 
also  their  valence  toward  HCl,  vary  remarkably,  a  table  of  all  these 
foods  is  given  on  page  250,  showing  how  much  hydrochloric  acid  they 
may  hold  in  combination  until  the  appearance  of  a  weak  but  distinct 
reaction  with  the  Baeyer-Giinzburg  reagent. 

In  the  two  columns  those  foods  occupy  the  first  places  which  com- 
bine with  the  least  amount  of  HCl;  those  which  combine  with  the 
greatest  amount  of  hydrochloric  acid  (meat,  poultr}^,  game,  fish, 
vegetables,  etc.)  stand  at  the  end  of  the  column. 

From  this  survey  it  appears  that  for  patients  with  h^^perchylia, 
veal,  beef,  mutton,  and  raw  ham  (which  hold  in  combination  two  or 
three  times  as  much  HCl  as  the  same  quantities  of  sweetbread,  liver 
pudding,  and  calf's  brain)  are  to  be  recommended  if  the  second  sys- 
tem on  the  preceding  page  is  selected.  For  the  same  reason  the 
Ivcube-Rosenthal  meat  solution,  which  in  itself  is  easily  digestible,  can 
be  recommended.  Cooked  ham  and  finely  minced  pork  are  also  suit- 
able meats.  Of  the  other  foods,  Swiss  cheese,  Roquefort,  pea  sau- 
sage, brick  cheese,  and  of  the  various  kinds  of  bread,  especially  pum- 
pernickel and  r\-e  bread  are  recommended  by  Fleischer — I  have  no 
personal  experience  with  this  form  of  diet.     \\'heat  bread  is  not  so 

*  Since  the  first  edition  of  this  work  my  experimental  results  and  practical  recom- 
mendations of  an  amylaceous  diet  for  hyperacidity  have  been  confirmed  by  Wold  Bach- 
mann  ("  Archiv  f.  Verdauungskrank.,"  Bd.  V,  S.  336),  by  Chr.  Jiirgensen,  and  J. 
Justesen  ("Zeitschr.  f.  diat.  u.  physikal.  Therap.,"  Bd.  Ill,  S.  541) — and  the  histological 
observations  have  been  confirmed  by  H.  Strauss  and  J-  S.  Myer  ("  Virchow's  Archiv," 
Bd.  CLiv). 


MEDICINAL  TREATMENT  OF   HYPERACIDITY.  827 

suitable,  as  700  gm.  of  it  are  necessar}^  to  combine  with  the  same 
quantity  of  HCl,  which  is  held  in  combination  by  300  gm.  of  pum- 
pernickel or  100  gm.  of  veal.  Beer  is  not  suitable.  Milk  is  to  be 
recommended,  both  on  account  of  its  digestibility  and  composition. 
If,  on  account  of  muscular  disturbances,  it  is  desired  to  avoid  large 
quantities  of  liquids,  condensed  milk  should  be  advised;  600  gm. 
milk,  condensed  to  one-fourth  of  its  volume,  combines  with  as  much 
HCl  as  100  gm.  veal.     Cocoa  is  also  to  be  recommended. 

If  gastric  distress  and  pain  appear  after  supper  before  bedtime, 
the  patient  should  drink  a  cup  of  lukewarm  milk,  bouillon  with  egg, 
and  meat  solution,  or  eat  raw  ham  scraped  fine,  or  one  egg,  which 
also  combines  with  a  great  deal  of  HCl  (see  p.  250). 

This  large  ingestion  of  proteid  and  albuminous  food,  especially 
advocated  by  Fleischer  for  hyperacidity,  does  not  lead  to  permanent 
relief,  in  the  author's  experience.  According  to  carefully  conducted 
experiments  and  analyses,  he  is  of  the  opinion  that  a  proteid  diet  may 
keep  up  a  hyperacidity  because  it  is  a  stronger  stimulation  to  HCl 
secretion  (see  pp.  197-199). 

(b)  Medicinal  Treatment. — We  refer  to  pages  335  to  338  in  expla- 
nation of  the  use  of  alkalies  in  hyperacidity.  Magnesia  is  preferable 
to  the  carbonates  because  it  can  not  form  chlorids,  which  may  irri- 
tate the  mucosa.  As  may  be  seen  from  the  table  (p.  250),  the  albu- 
minates of  the  foods  may  take  up  considerable  quantities  of  HCl,  and 
after  their  transformation  into  peptone  hydrochlorate  they  aid  the 
nutrition  of  the  body,  v/hich  is  not  the  case  with  the  chlorids.  The 
digestive  products  of  albumin,  hemialbuminose,  and  peptone,  com- 
bine with  more  HCl  in  the  formation  of  their  hydrochlorate  com- 
pounds than  albumin  itself  (peptone  almost  twice  the  amount),  and 
the  peptonizing  as  well  as  the  decomposition  of  the  peptone  hydro- 
chlorate in  the  blood  require  some  time,  so  that  the  HCl  combined 
with  it  does  not  readily  become  free  again. 

Some  of  the  alkalies  may  be  taken  in  the  form  of  alkaline  mineral 
water — Saratoga  Vichy,  St.  Louis  Spring  (Mich.),  Apollinaris,  Biliner 
water,  Fachinger,  Selters,  and  French  Vichy.  Magnesia  usta,  bi- 
carbonate of  soda,  sodium  biborate  (Jaworski,  L.  Wolff),  are  best 
prescribed  as  indicated  on  pages  336  to  338.  If  there  is  an  inclina- 
tion to  the  formation  of  gases,  the  bicarbonate  of  soda  is  to  be  re- 
placed by  magnesia  usta  in  order  not  to  increase  the  amount  of  gas 
by  the  CO2  which  is  set  free  from  the  former.     Magnesia  usta  has 


828  NKUROSKS   OP   SECRETION. 

also  the  advantage  of  forming  a  chlorid  which  has  a  mild  aperient 
effect.     The  following  are  the  author's  favorite  formulae : 

li.     Magnes.  ustse, lo.o 

Sodii  bicarb., 

Pulv.   rad.  rhei, aa    5.0 

Ext.  belladonnse, 0.3  M. 

SiG. — One-half  of  a  teaspoon ful  three-quarters  of  an  hour  after  meals. 

Or— 

H  .      Sodii  bicarb. , 

Potass,  carbonat., 

Magnes.  ustse, aa    5.0 

Ext.  belladonnas, 0.25 

Sacchar.  lactis, 20.0  M. 

SiG. — One-half  of  a  teaspoonful  one  hour  after  each  meal. 

(See  also  formulEe  on  p.  339.) 

Extract  of  belladonna  or  atropin  has  a  decided  effect  in  checking 
the  secretion  of  gastric  juice;  in  some  experiments  the  amount  of 
HCl  was  reduced  to  one-third  or  one-half  the  normal  amount  (Riegel, 
"Verhandl.  d.  Congress,  f.  innere  Medicin,"  1899,  S.  328). 

According  to  Jaworski's  experiments,  the  continued  use  of  large 
quantities  of  Carlsbad  salt  and  the  thermal  waters  of  Carlsbad  reduce 
the  secretion  of  the  acids  of  the  stomach;  this  might  explain  the 
beneficial  influence  of  a  protracted  stay  at  Carlsbad  (see  p.  337). 
We  are  assured  that  the  Bedford  and  the  Saratoga  Carlsbad  mineral 
waters  in  our  country  have  an  equally  beneficial  effect.  If  the  pains 
in  the  region  of  the  stomach  continue  in  spite  of  the  remedies  dis- 
cussed thus  far,  narcotics  are  prescribed,  especially  extract  of  bella- 
donna (0.03  gm.  daily)  and  atropin  sulphate  (0.0005  to  0.00 1  gm., 
or  y^Q-  of  a  grain),  given  with  advantage,  together  with  magnesia 
usta  or  ammoniomagnesium  phosphate — substances  which  not  only 
have  the  effect  of  reducing  pain,  but  also  inhibit  the  secretion  of  the 
glands;  codein  phosphate  (0.03  gm.  i  to  |^  daily)  is  a  reliable  drug 
for  this  purpose.  Cocain  muriate  is  not  suitable  on  account  of  the 
fact  that  its  effect  passes  away  rapidly,  but  bromid  of  sodium  and 
bromid  of  ammonium  (2.5  to  4.0  in  twenty-four  hours),  when  taken 
for  some  time,  often  do  good  service.  Strontium  bromid  is  even 
better  tolerated  than  the  sodium  or  ammonium  salt. 

On  the  other  hand,  the  use  of  morphin  muriate  must  be  as  limited 
as  possible.  According  to  Hitzig  and  Alt,  morphin  muriate  is,  to  a 
great  extent,  excreted  in  the  gastric  juice  and  also  with  the  saliva, 
and  therefore  reaches  the  stomach  again  after  absorption.     Small 


MEDICINAL   TREATMENT   OF    HYPERACIDITY.  829 

quantities  of  morphin,  however,  excite  the  nerves  more  than  they 
calm  them. 

If  the  patients  complain  of  severe  pains  even  on  an  empty  stomach 
(without  being  able  to  prove  supersecretion  or  hyperesthesia),  then 
lavage  of  the  stomach,  irrigation  of  the  mucous  membrane,  and 
internal  douches,  which  were  first  recommended  by  Malbranc,  will 
give  more  permanent  relief. 

With  very  stubborn  cramp-like  pains  in  the  region  of  the  pylorus 
(pylorospasm)  there  is  nothing  to  be  done  but  to  remove  the  strongly 
acid  contents  of  the  stomach  with  the  tube  and  to  wash  out  the 
stomach,  first  with  lukewarm  water,  then  with  bicarbonate  of  sodium, 
and  to  leave  a  small  part  of  the  latter  in  the  organ. 

Jaworski's  treatment  by  stronger  or  weaker  effervescent  alkaline 
waters  has  proved  useful  in  our  experience.  The  following  are  the 
formulae : 

Alkaline  Effervescent  Solution. 

I.  II. 

Strong.      Weak. 

Sodium  bicarbonate, 8.0  5.0 

Sodium  salicyl., 2.5  2.0 

Sodium  biborat., 2.0  l.o 

Add  above  to  one  liter  (one  quart)  of  carbonated  water. 

Directions. — On  an  empty  stomach  take  J^  of  a  tumblerful  of  the  stronger  solution, 
No.  I,  in  the  morning.  After  each  meal  drink  3^  to  ^  of  a  tumblerful  of  the  milder 
solution,  No.  II. 

These  solutions  are  markedly  efficacious  if  the  hyperacidity  is 
associated  with  uric  acid  diathesis. 

The  electrical  treatment  has  been  used  successfully  by  Einhorn  for 
this  purpose,  and  he  especially  favors  the  internal  galvanization  of 
the  stomach.  Since  the  anode  has  a  calming  effect  upon  the  irritated 
nerves  (Heidenhain),  it  is  perhaps  best  to  introduce  the  anode  with 
the  intragastric  electrode  into  the  stomach  filled  with  moderate 
quantities  of  lukewarm  water,  and  to  apply  the  cathode  to  the  ster- 
num, epigastrium,  or  spine. 

Constipation  will,  as  a  rule,  be  relieved  by  neutralization  of  the 
excess  of  HCl,  but  in  the  rare  cases  in  which  it  is  not,  it  is  to  be  fought 
w^ith  rhubarb  preparations  (pulv.  rad.  rhei,  40.0;  natr.  sulph.,  20.0), 
Carlsbad  Sprudel  salts,  by  injections,  massage  of  the  intestines,  and 
glycerin  suppositories.  Injections  of  eight  ounces  of  olive  oil  into 
the  colon,  according  to  Kleiner's  method,  is  efficacious  in  many  cases. 
Since  superacidity  is  frequently  a  neurosis,   we  must,   in  general, 


830  NEUROSES   OF   SECRETION. 

influence  the  nervous  system  favorably  by  a  sojourn  in  the  country, 
in  the  mountains,  at  the  seashore,  by  cold  rubbings,  g}^mnastics,  and 
abstention  from  severe  mental  labor.  A  treatment  recommended 
by  Biedert  and  Langermann  (/.  c.)  has  been  found  serviceable  by  the 
author.  The  stomach  is  first  washed  out  by  a  solution  of  sodium 
bicarbonate.  When  the  water  returns  clean,  we  pour  in  a  one  per 
cent,  suspension  of  magnesia  usta;  when  this  has  run  out,  it  is  fol- 
lowed by  a  one-half  per  cent,  solution  of  tannin.  In  the  place  of  the 
latter,  particularly  when  it  is  not  well  tolerated,  we  often  use  a  sus- 
pension of  bismuth  subnitrate ;  when  the  pains  are  severe,  the  author 
prefers  lavage,  with  a  suspension  of  one  dram  each  of  bismuth  sub- 
gallate  and  bismuth  subnitrate  in  one  quart  of  warm  water. 

PERIODICAL  ATYPICAL  FLOW  OF   GASTRIC  JUICE   (Gastroxynsis 
{Rossbach),  Gastroxie  {Lepine),  Gastrosuccorrhea  Periodica 

{Reichmann) ). 

Gastroxynsis,  or  periodical  flow  of  gastric  juice,  is  an  atypical 
secretion  of  the  peptic  glands — atypical  because  it  does  not  occur 
after  a  normal  digestive  stimulation,  but  rather  when  the  stomach  is 
empty.  The  attacks  are  associated  with  intense  gastric  distress, 
severe  spasmodic  pain,  and  vomiting  of  considerable  quantities  of 
very  acid  gastric  juice.  This  peculiar  neurosis  is  found  almost  ex- 
clusively among  the  educated  classes,  and  particularly  among  those 
individuals  who  are  subjected  to  unremitting  mental  exertion.  In 
exceptional  cases  persons  belonging  to  the  laboring  classes  are 
attacked  by  it.  The  malady  occurs  in  attacks  which  last  from  one 
to  three  days,  returning  in  some  instances  ever^^  week,  and  in  others 
at  intervals  of  months.  The  attacks  are  more  frequent  when  the 
mental  exertion  is  severest,  and  become  rare  as  soon  as  pauses  of 
mental  rest  intervene.  During  vacation  of  these  brain- workers, 
or  sojourn  at  the  seashore  or  in  the  mountains,  the  attacks  disappear 
entirely,  to  return  again  when  the  sufferer  applies  himself  to  his  pro- 
fession. The  pains,  which  are  most  probabty  caused  by  irritation 
of  the  mucosa,  by  the  intensely  acid  secretion,  are  generalty  pre- 
ceded by  nausea,  eructation,  and  pyrosis.  Eventually  the  emesis 
of  large  quantities  of  acid  liquids  supervenes,  and,  as  a  rule,  termi- 
nates the  attack.  The  sufferers  generally  recuperate  quickly.  Jiir- 
gensen  and  Ewald  have  reported  cases  of  typical  migraine  that  were 
also  associated  with  superacidity.  Rossbach  ("Deutsch.  Archiv  f. 
klin.  Med.,"  Bd.  xxxv,  1885)  and  Rosenthal  (/.  c.)  have  suggested 


SYMPTOMATOLOGY   OF    GASTROXYNSIS.  83 1 

hypotheses  attempting  to  explain  the  pathogenesis  of  periodic  flow 
of  gastric  juice;  their  theories  are  not  supported  by  experimental 
evidence,  and  have  not  cleared  up  the  subject. 

Etiology. — Among  the  incidental  causes  we  meet  with  excessive 
and  exhausting  mental  exertion,  intense  emotional  excitement, 
anger,  nicotin  poisoning,  and  occasionally  dietetic  errors.  The  so- 
called  periodic  flow  of  gastric  juice,  as  first  described  by  Reichmann 
("Berlin,  klin.  Wochenschr.,"  1882,  Nr.  40),  and  the  gastroxynsis 
of  Rossbach,  are,  in  our  opinion,  simply  phases  of  the  same  neurosis, 
not  different  diseases. 

Symptomatology. — The  attacks  occur  very  acutely,  more  fre- 
quently on  an  empty  stomach,  and  with  a  feeling  of  pressure  in  the 
head  increasing  to  intense  headache,  pain  in  and  over  the  e^^es,  dis- 
tress, pressure,  and  fullness  in  the  stomach,  increasing  to  gastralgia. 
Eructation,  pyrosis,  and  nausea  usher  in  abundant  vomiting  of  highly 
acid  mucous  masses;  the  quantity  of  HCl  in  the  vomit  may  be  fifty 
per  cent,  and  even  exceed  this.  Repeated  vomiting  will  bring  up 
mucus  and  bile.  When  the  vomit  occurs  while  the  stomach  still  con- 
tains ingesta,  this  will  show  the  same  chemical  reactions  as  are  found 
in  hyperacidity.  The  drinking  of  water  relieves  the  gastric  distress 
by  diluting  the  acid,  but  generally  increases  the  vomiting.  In  our 
experience  the  attacks  occur,  as  a  rule,  in  the  middle  of  the  night,  or 
in  the  early  hours  of  the  morning.  The  patient  has  a  very  pale 
appearance,  and  the  extremities  are  frequently  cold.  A  few  hours 
after  the  first  vomiting  of  gastric  juice  the  attack  may  be  repeated, 
and  again  an  equally  large  quantity  of  gastric  secretion  containing 
no  food  particles  whatever  may  be  vomited.  In  a  case  which  the 
author  saw  in  consultation  with  Dr.  J.  B.  Schwatka,  of  Baltimore, 
the  patient  vomited  surprisingly  large  quantities  of  pure  straw- 
colored  gastric  juice.  The  amount  was  between  510  and  600  c.c. 
every  time  he  vomited,  which  usually  was  three  or  four  times  in 
twenty-four  hours.  The  patient  retained  no  food  for  eight  days,  was 
fed  by  nutritive  enemata,  and  finally  recovered  under  lavage  with 
bicarbonate  of  sodium  and  spra5ang  the  stomach  with  nitrate  of 
silver  i  ;  1000.  At  night  a  hypodermic  of  morphin,  j  gr.,  and 
atropin,  y^fj-  gr.,  was  given.  The  acidity  of  vomit  was  3.5  per  thou- 
sand (free  HCl).  Occasionally,  the  gastric  pains  are  the  only  symp- 
tom, and  headache  follows  later  on ;  in  fact,  the  symptoms  might  be 
difl'erentiated  into  gastric  and  cerebral  symptoms — at  times  the 
former  prevail,  and  at  others,  the  latter.     The  highly  acid  liquids  in 


832  NEUROSES   OF   SECRETION. 

the  stomach  very  Hkely  cause  a  reflex  spasmodic  pylorospasm.  Eruc- 
tation, insufficiency  of  the  cardia,  and  pneumatosis  are  frequent 
accompaniments.  Periodical  atypical  flow  of  gastric  juice  may  be 
an  independent  neurosis  of  secretion,  or  reflexly  caused  by  diseases  of 
the  central  nervous  system.  The  gastric  crises  occurring  in  tabes 
have  been  classed  with  periodical  secretion  by  some  authors,  but 
according  to  von  Noorden  ("Charite  Annalen,"  1890),  Bouveret  {I. 
c,  p.  680),  and  Boas  ("Deutsch.  med.  Wochenschr.,"  1889,  Nr.  42) 
the  liquids  vomited  in  gastric  crises  are  not  always  acid,  and  fre- 
quently may  be  found  alkaline.  They  are  not  associated  with  the 
very  severe  phenomena  of  highly  increased  acidity  of  gastric  juice ; 
namely,  the  strong  pyrosis,  and  the  feeling  of  a  corrosive  substance 
in  the  stomach.  Bouveret  has  expressed  his  doubt  concerning  the 
existence  of  a  central  form  of  periodical  gastrosuccorrhea. 

Diagnosis. — Gastroxynsis  may  be  confounded  with  the  migraine 
associated  with  gastric  symptoms,-  with  intermittent  forms  of  severe 
hyperchylia,  and  with  the  gastric  crises.  The  diagnosis  can  be  made 
by  chemical  analysis  of  the  vomited  matter.  The  attacks  usually 
occur  in  the  midst  of  good  health,  and  the  severe  thirst,  loss  of  appe- 
tite, cephalalgia,  and  great  prostration  are  characteristic  symptoms. 
Rossbach  found  an  acidity  of  four  per  thousand  (HCl)  in  one  of  his 
cases,  and  Boas  found  that  there  was  a  hyperacidity  even  in  the 
intervals  between  the  attacks,  and  that  the  amount  of  gastric  juice 
during  the  attacks  was  not  much  increased  as  compared  to  that 
found  in  the  intervals. 

Example  I. — Miss  M.  G.,  age  twenty-four,  of  neuropathic  extraction,  has 
frequently  had  attacks  of  vomiting  and  gastric  pain  during  childhood.  For 
about  six  years  she  has  suffered  from  intense  pyrosis,  which  was  relieved  by 
bicarbonate  of  sodium  tablets.  Sometimes  the  heartburn  ceased  after  the  in- 
gestion of  food.  She  is  a  music  teacher,  and  frequently  spends  eight  to  ten 
hours  a  day  teaching  pupils  and  giving  singing  lessons.  The  appetite  is  at  all 
times  very  good,  bowels  slightly  constipated.  The  acidity  after  our  double 
test-meal  taken  in  the  interval  between  the  attacks  is  equal  to  0.3  per  cent.  HCl. 
About  once  a  week  she  has  distressing  attacks  of  gastralgia,  associated  with 
severe  headache  and  vomiting  of  very  acid  liquid  masses.  The  attacks  occur 
generally  between  two  and  three  o'clock  in  the  morning,  when  she  has  spent 
a  day  at  hard  work  teaching  pupils.  The  patient  awakes  suddenly  with  a  feel- 
ing extending  from  her  stomach  to  her  throat,  which  is  described  as  a  twisting 
of  the  gullet.  Severe  cephalalgia,  giddiness,  nausea,  and  vomiting  follow. 
Sometimes  she  does  not  vomit,  but  the  attack  is  passed  off  by  rapidly  drinking 
a  half-pint  of  water  with  a  teaspoonful  of  bicarbonate  of  soda.  Physical  ex- 
amination, entirely  negative.  Urine,  the  indican  is  increased.  Urea,  uric  acid, 
ratio  high.     No  splashing  sound  in  the  stomach  prior  to  ingestion  of  food  or 


TREATMENT   OF    GASTROXYNSIS.  833 

drink.  Acidity  of  filtrateof  vomited  matter,  which  apparently  was  free  from  bile, 
was  equal  to  2.8  per  thousand  (HCl),  or  0.28  per  cent.  The  fact  that  the  acidity 
was  less  during  the  attack  than  during  the  intervals,  suggested  that  the  HCl 
had  been  neutralized  through  bile,  duodenal  secretions,  or  saliva,  but  the  care- 
ful examination  for  these  constituents  was  negative.  During  a  summer  vaca- 
tion in  which  the  patient  undertook  a  trip  to  Europe,  she  vomited  daily  from 
sea-sickness,  but  in  three  months,  while  she  was  in  Germany,  she  did  not  have 
one  attack.  On  returning,  the  acidity,  after  a  similar  test-meal,  as  before  stated, 
was  equal  to  1.5  per  thousand  (HCl).     General  condition  much  improved. 

Exatnple  II. — This  case  is  that  of  a  colleague,  a  friend  of  the  author's,  who 
has  described  his  case  with  great  accuracy  on  repeated  occasions.  The  attacks 
usually  occur  at  night,  associated  with  headache  and  gastric  distress,  and  cul- 
minate in  the  vomiting  of  large  masses  of  highly  acid  material.  The  doctor  is 
an  indefatigable  brain-worker,  allowing  himself  very  little,  if  any,  recreation. 
His  general  nutrition  is  good,  and  he  has  found  that  his  attacks  are  rapidly 
relieved  by  the  taking  of  ordinary  cane-sugar  (Ewald). 

Periodical  vomiting,  when  associated  with  hyperacidity,  must  be 
carefully  distinguished  from  gastroxynsis. 

Treatment. — This  includes,  in  the  first  place,  the  avoidance  of 
stimulants  and  narcotics:  alcohol  and  tobacco,  as  well  as  strong 
coffee.  It  is  most  essential  that  the  patients  should  avoid  mental 
overwork.  They  should,  in  fact,  refrain  from  brain- work  altogether, 
and  allow  themselves  three  or  four  months  a  year  to  enjoy  recreation 
in  the  mountains  or  at  the  seashore.  Physical  exercise  should  be 
indulged  in  moderately  but  systematically.  The  bicycle  is  an  ex- 
cellent remedy  for  periodical  flow  of  gastric  juice ;  and  also  horseback 
riding,  swimming,  rowing,  fencing,  gymnastic  exercises,  and  outdoor 
games.  During  the  attack  itself,  the  effects  of  the  excess  of  acid 
should  be  counterbalanced  by  copious  drafts  of  suspensions  of  cal- 
cined magnesia,  ammoniomagnesium  phosphate,  or  bicarbonate  of 
sodium.  When  the  vomiting  has  occurred  at  short  intervals,  one 
should  not  hesitate  to  pass  the  stomach-tube,  wash  out  the  stomach 
with  sodium  bicarbonate,  and  afterward  treat  the  mucosa  with  sus- 
pensions pf  bismuth  subgallate  (.5ij  to  Oj)  or  with  argentic  nitrate, 
I  :  1000.  A  mustard  plaster  should  be  placed  over  the  epigastrium. 
If  this  can  not  be  conveniently  had,  a  hot-water  bag  will  act  similarly. 
The  bromid  of  strontium  and  bromid  of  ammonium,  in  doses  of  thirty 
grains  three  times  a  day,  have  an  undeniable  effect  upon  the  fre- 
quency of  the  attacks.  The  diet  should  be  carefully  adjusted  to 
the  digestive  capacity  of  the  stomach.  We  usually  recommend 
Penzoldt's  diet  order,  which  is  given  among  the  diet  lists.  In  the 
intervals  between  the  attacks  the  patients  should  undergo  treatment 


834  NEUROSES   OF   SECRETION, 

as  outlined  for  hyperacidity.  Belladonna  or  atropia  are  often  valua- 
ble aids  to  the  treatment;  their  mode  of  action  has  been  explained 
on  page  828. 

CHRONIC   CONTINUOUS   FLOW   OF   GASTRIC  JUICE  (Chronic 

Hyper-  or  Supersecretion  {Riegel),  Gastrosuccorrhea 

Chronica  {Reickmatm)). 

We  have  our  doubts  whether  such  a  condition  of  permanent  irri- 
tation of  the  gastric  secretory  nerves  and  uninterrupted  secretion 
exists  as  a  primary  disorder.  Chronic  gastrosuccorrhea,  which  Reich- 
mann  claimed  to  have  observed  and  first  described  in  1882  ("Berlin, 
klin.  Wochenschr.,"  1882,  Nr.  40;  1884,  Nr.  48;  1887,  Nr.  12)  as  a 
disease  peculiar  to  itself,  is  stated  by  him  to  be  a  disorder  charac- 
terized by  the  chronic  uninterrupted  secretion  of  gastric  juice  at  all 
times,  even  when  there  is  no  food  in  the  stomach.  In  a  fasting  con- 
dition in  the  morning,  Reichmann  and  others  claim  that  gastric  juice 
could  be  drawn  from  the  stomach  in  these  cases.  As  we  have  seen 
in  the  description  of  the  organic  gastric  diseases,  particularly  in  severe 
reflex  neuroses,  in  dilation,  and  gastric  ulcer,  continued  flow  of  gas- 
tric juice  is  a  frequent  symptom,  associating  itself  with  alteration  and 
loss  of  substance  in  the  mucosa.  Occurring  as  a  secondary  afifection, 
it  may  still  be  able  to  effect  severe  damage  to  the  gastric  walls.  The 
diagnosis  of  this  hypothetical  disease  hinges  upon  the  presence  of 
gastric  juice  containing  HCl  and  ferments  in  the  jejune  or  fasting 
stomach.  This  question  has  been  very  carefully  investigated  by 
Schreiber  ("Deutsch.  Archiv  f.  klin.  Medizin,"  Bd.  Liii,  S.  90).  He 
found,  in  Konigsberg,  that  in  over  70  per  cent,  of  his  patients  a  diges- 
tive secretion  was  contained  in  the  fasting  stomach. 

Physiologically  speaking,  an  absolutely  clean  and  empty  stomach 
should,  in  the  morning,  contain  no  gastric  juice,  as  the  glandular 
apparatus  is  normally  in  a  resting  state,  but  practically  the  human 
stomach  is  very  rarely  in  this  condition.  It  contains  at-  all  times 
epithelial  detritus,  dust,  bacteria,  secretions  from  the  mouth,  larj-nx, 
and  pharynx,  particularly  saliva,  which  at  different  intervals  are 
swallowed  consciously  or  unconsciously.  These  albuminous,  mu- 
cous masses,  which  are  generally  weakly  alkaline,  and  which  collect 
particularly  during  the  night,  incite  the  specific  gastric  glands  to 
secrete  their  physiological  product  just  as  any  weakly  albuminous 
food  would  do.  This  is  a  kind  of  pseudo  or  frustrate  digestion,  be- 
cause, so  far  as  nutrition  is  concerned,  this  slow  digestion  going  on 


NATURE   OF   SUPERSECRETION.  835 

constantly  is  of  no  value.  This  slight  pseudodigestion,  which,  ac- 
cording to  Schreiber,  is  present  perhaps  at  all  times,  is  augmented 
and  multiplied  by  the  permanent  presence  of  actual  food  masses  when 
the  stomach  is  dilated.  The  frustrate  digestion  becomes  a  real  one. 
In  all  dilations  with  retention  of  food  we  have  a  permanent,  real  diges- 
tion, and  an  augmented  permanent  secretion  corresponding  to  it. 

This  so-called  continued  hypersecretion  leads  to  the  digestion  and 
assimilation  of  proteids  and  albuminous  bodies  of  the  food,  while  the 
normal  digestion  of  carbohydrates  is  impeded.  The  phenomena  that 
are  claimed  to  be  typical  of  chronic  continued  hypersecretion  are  un- 
avoidable consequences  of  dilation.  The  cardinal  point  of  distinc- 
tion— namely,  that  digestive  secretions  are  contained  in  the  stomach 
on  the  morning  following  a  very  effective  washing  out  executed  the 
evening  before — is  certainly  not  peculiar  to  chronic  h^^persecretion, 
but  occurs  also  with  dilation.  Schreiber  has  called  attention  to  the 
fact  that  it  is  exceedingly  difficult,  even  impossible,  to  completely 
evacuate  and  clean  out  a  dilated  stomach.  During  gastrotomies 
food  substances  have  been  found  in  the  stomach,  notwithstanding 
very  energetic  efforts  to  free  it  of  all  remnants  beforehand.  When  a 
patient  with  a  dilated  stomach  is  to  be  examined  for  the  gastric  con- 
tents prior  to  taking  food  in  the  morning,  it  is  expedient  not  to  be 
satisfied  with  the  simple  expression  method  of  Ewald,  when  this  is 
negative,  but  to  place  the  patient  in  a  horizontal  position,  and,  while 
he  makes  efforts  at  straining  as  if  he  were  bearing  down  for  stool,  the 
operator  must  compress  the  stomach  near  the  fundus,  which,  in  these 
cases,  is  sometimes  found  below  the  umbilicus. 

In  the  reports  of  a  number  of  advocates  of  chronic  hypersecretion 
as  a  primary  disease  per  se,  one  frequently  finds  that  the  authors 
state  that  small  quantities  of  food  remnants  were  found  in  the  fasting 
stomach.  The  argument  generally  follows  that  such  small  quantities 
of  food  could  not  be  the  cause  of  the  large  quantity  of  gastric  juice 
secreted,  contending  that  the  latter  must  have  been  secreted  spon- 
taneously. At  the  same  time,  an  illogical  position  is  demonstrated 
by  the  assertion  that  the  momentary  contact  of  a  soft  stomach-tube 
with  the  mucosa  is  the  cause  of  the  secretion  of  eighty  to  one  hundred 
centimeters  of  gastric  juice.  This  assertion,  it  should  not  be  forgot- 
ten, is  made  by  a  number  of  those  who  have  found  food  remnants  in 
the  stomachs  of  these  cases.  That  is  to  say,  the  ejffort  is  made  to 
ignore  the  physiological  stimulus  of  food  which  is  contained  in  the 
stomach  for  hours,  and  emphasize  the  rather  insignificant  momentary 
55 


836  NEUROSES   OE   SECRETION. 

stimulation  caused  by  the  introduction  of  a  tube.  As  Schreiber 
correctly  points  out,  the  freedom  of  the  stomach  contents  from  food 
particles  is  very  often  only  an  apparent,  not  a  real,  one.  It  is  caused 
by  imperfections  in  our  methods  of  investigation,  and  when  one 
closely  considers  the  symptoms  of  chronic  hypersecretion,  as  they 
are  described  by  the  adherents  of  Reichmann,  they  seem,  in  many 
cases,  to  be  identical  with  those  of  dilation.  We  have  been  able  to 
exclude  the  hypothetical  factor  of  the  stomach-tube  in  causing  a 
secretion  of  gastric  juice  in  a  normal  fasting  stomach.  In  a  number 
of  our  students  who  consented  to  take  a  hypodermic  injection  of 
apomorphin  before  they  had  eaten  anything  in  the  morning,  we 
demonstrated  the  presence  of  HCl  in  the  vomited  matter.  There  is, 
therefore,  in  some  persons  and  to  some  degree  a  physiological  normal 
continued  secretion  of  gastric  juice,  as  Schreiber  correctly  asserts 
("Deutsche  medizin.  Wochenschr.,"  1894,  Nr.  18-21);  in  these  the 
stomach  secretes  gastric  juice  normally  and  independently  of  the  in- 
gestion of  food.  Ewald  and  Boas  cite  a  case  which  has  been  quoted 
by  Riegel  ("Deutsche  med.  Wochenschr.,"  1893,  Nr.  31,  32)  in  oppo- 
sition to  the  views  of  Schreiber.  This  female  patient  had  a  peculiar 
gastric  neurosis  founded  on  a  hysterical  basis.  For  six  years  the 
patient  vomited  everything  that  was  ingested;  fluids  were  vomited 
immediately,  and  solid  food  after  two  to  four  hours.  When  she  had 
taken  100  c.c.  of  water  on  an  empty  stomach  in  the  morning,  she 
vomited  it  very  soon  thereafter,  and  Ewald  and  Boas  could  not  find 
free  HCl  in  it,  and  therefore  concluded  that  the  fasting  stomach 
secretes  no  gastric  juice  under  normal  conditions.  Aside  from  the 
fact  that  this  woman  may  have  had  a  spasm  of  the  esophagus  or 
cardia  preventing  the  small  amount  of  water  from  ever  reaching  the 
stomach,  it  is  not  fair  to  decide  a  physiological  question  from  results 
obtained  from  a  chronic  neurotic  patient;  for,  as  we  know,  in  this 
class  of  individuals  the  greatest  variation  in  the  state  of  the  gastric 
secretion  exists  (see  Heterochylia).  The  results  obtained  on  human 
beings  with  gastric  fistulse  (see  W.  Beaumont  on  his  Canadian 
hunter,  Alexis  St.  Martin,  also  the  cases  of  Kretschy-Richet)  are 
inadmissible  to  the  solution  of  this  physiological  question,  because 
they  are  made  on  individuals  under  pathological  conditions. 

The  existence  of  HCl  in  normal  stomachs  may  be  demonstrated 
by  giving  healthy  individuals  long  pieces  of  thin  thread,  which  with 
some  practice  they  can  learn  to  swallow  on  an  empty  stomach ;  this 
silk  or  thread  is  so  thin  that  it  does  not  irritate  the  gastric  wall  to 


TYPES    OF    CHRONIC    GASTROSUCCORRHEA.  837 

any  degree,  at  least  not  so  much  as  a  stomach-tube ;  the  thread  is 
then  rapidly  withdrawn  and  pressed  between  pieces  of  Congo  paper, 
when  it  can  be  seen  that  the  Congo  paper  turns  dark  blue.  We  have 
also  introduced  the  thread  already  stained  with  Congo  red,  and  ob- 
tained the  blue  discoloration  from  fasting  normal  stomachs.  Un- 
doubtedly there  are  great  individual  variations  in  the  genuine  as  well 
as  in  the  frustrate  digestion,  caused  by  the  secretive  power  of  the 
glands  and  the  character  of  the  food.  Morbid  conditions  influence 
both  of  these  types  of  digestion  quantitatively  and  qualitatively. 
Conditions  which  incite  the  glands  will  increase  the  HCl,  and  condi- 
tions which  weaken  the  mucosa,  such  as  gastritis,  diminish  the  HCl 
during  real  digestion  after  meals,  as  well  as  during  the  frustrate  di- 
gestion occurring  during  the  night  and  on  a  fasting  stomach.  These 
variations  are  also  frequently  found  in  dilation.  If  the  gastrectasia 
occurred  on  the  basis  of  an  ulcer,  the  true  secretion,  as  well  as  the 
permanent  secretion  of  a  frustrate  character,  will  be  increased,  and 
reversely,  when  carcinoma  or  chronic  gastritis  is  present,  together 
with  dilation,  both  kinds  of  secretion  will  be  diminished,  or  they  may 
not  contain  HCl  at  all.  In  diagnosing  a  dilated  stomach  it  is  impor- 
tant to  bear  in  mind  that  a  stomach  may  be  very  much  enlarged  and 
still  its  greater  curvature  may  not  have  descended  to  any  considera- 
ble extent.  Frequently  the  very  cause  that  has  brought  about  dila- 
tion— for  instance,  perigastritis,  or  adhesions  about  the  stomach — 
makes  a  descent  of  the  greater  curvature  impossible,  simply  because 
it  can  not  descend,  being  bound  down  into  this  position  in  the  upper 
part  of  the  abdomen  by  inflammatory  adhesions.  Therefore  it  is 
possible  that  a  stomach  may  be  dilated  and  yet  give  no  splashing 
sound  about  the  neighborhood  of  the  umbilicus,  nor  need  it  be  much 
displaced  from  its  normal  position.  The  stomach  may,  in  fact,  en- 
large in  an  upward  and  backward  or  lateral  direction  when  its  descent 
is  made  impossible  by  adhesions.  The  presence  or  absence  of  food 
particles  in  contents  drawn  from  the  fasting  stomach  can  not  always 
be  recognized  by  the  naked  eye.  What  resembles  a  turbid  liquid 
free  from  ingesta  to  the  naked  eye,  will  often  show  undigested  rice, 
bread,  and  other  carbohydrates  under  the  microscope.  There  is, 
however,  a  second  class  of  cases  of  chronic  continuous  flow  of  gastric 
juice  in  which  absolutely  no  organic  disease  of  the  stomach  and  no 
dilation  are  demonstrable.  These  are  the  typical  cases  of  Reich- 
mann  and  Riegel,  and  due  to  excessive  reaction  of  the  gastric  mucosa 
to  the  stimulation  of  the  ingesta.     We  have  personally  seen  cases 


838  NEJUROSES   OF   SECRETION. 

which,  according  to  the  description  of  Reichmann  and  Riegel,  would 
have  to  be  classed  as  typical  chronic  hypersecretion,  in  which  the 
stomach  was  apparently  in  its  normal  place,  and  no  organic  gastric 
disease  could  be  determined  with  the  most  exact  methods  of  exami- 
nation. In  three  of  these  cases  we  could  extract  from  100  to  150  c.c. 
of  gastric  juice  from  the  fasting  stomach,  apparently  containing  no 
food  contents  but  occasionally  containing  traces  of  bile.  The  acidity 
of  this  secretion  when  filtered  was  equal  to  80°  HCl  by  decinormal 
solution  of  sodium  hydroxid  and  either  Congo  or  dimethylamido- 
benzol. 

The  total  acidity  was  no  in  one  of  the  cases — that  of  a  young 
bank  clerk  twenty-four  years  of  age.  He  also  suffered. from  consti- 
pation, pyrosis,  increasing  to  pain,  and  vomiting  which  came  on  very 
soon  after  meals.  The  examination  of  the  contents  one  hour  after 
our  complex  test-meal  gave  the  following  results :  Total  acidity,  108; 
free  HCl,  84;  biuret  reaction,  positive;  patellar  and  pupillary  re- 
flexes, normal.  For  eight  consecutive  days  free  HCl  and  gastric  fer- 
ments could  be  detected  in  the  contents  from  the  fasting  stomach. 
As  his  trouble  was  persistent  and  he  was  determined  to  get  well,  he 
consented  to  a  course  of  exclusive  rectal  feeding.  He  was  nourished 
for  ten  days  by  the  rectum,  and  at  the  same  time  his  stomach  was 
washed  out  with  suspensions  of  magnesia  usta  every  day.  Under 
these  conditions,  when  no  food  was  ingested  per  os,  the  gastrosuccor- 
rhea  rapidly  diminished,  and  disappeared  entirely  on  the  fourth  day, 
so  that  not  even  the  swallowed  masses  of  mucus  and  saliva  could 
sufficiently  stimulate  the  mucosa  to  produce  a  secretion  of  HCl.  This 
has  occurred  in  three  of  our  cases  where  the  amounts  of  gastric  juice 
found  on  an  empty  stomach  exceeded  100  c.c.  A  second  one  of  these 
cases  was  that  of  a  young  girl  with  Chronic  flow  of  gastric  juice,  who 
was  operated  on  upon  our  suggestion  by  Dr.  R.  W.  Johnson  at  the 
Maryland  General  Hospital.  After  the  abdomen  was  opened  and 
the  stomach  incised,  no  anatomical  cause  for  the  persistent  vomiting 
and  gastralgia  could  be  detected.  On  replacing  the  stomach,  how- 
ever, and  inserting  the  finger  into  the  pylorus,  a  rather  sharp  bend  in 
the  duodenum  was  evident  to  the  author.  Undoubtedly  this  kink 
became  more  manifest  when  food  was  ingested,  the  stomach  thereby 
dragging  upon  this  acute  angle  in  the  duodenum.  It  was  one  of  those 
cases  of  motor  insufficiency  which  Broadbent  has  described  ("British 
Medical  Jour.,"  vol.  11,  1893,  pp.  1 193  and  1268)  due  to  kinking  of  the 
duodenum  by  an  abnormally  short  duodenohepatic  ligament.     Dur- 


CONCLUSIONS  REGARDING  CHRONIC  HYPERSECRETION.    839 

ing  the  operation  the  pylorus  was  also  enlarged  by  sewing  together 
the  oblique  incision  which  had  been  made  (it  is  true  only  for  explora- 
tive reasons),  but  was  in  closing  up  sutured  in  such  a  way  as  to  re- 
semble a  pyloroplastic  operation.  The  patient  made  a  perfect  recov- 
ery, and  there  was  no  more  gastrosuocorrhea,  vomiting,  or  gastralgia. 
She  remained  in  the  hospital  for  two  months  after  the  operation, 
and  was  not  supplied  with  specially  prepared  diet,  but  lived  upon  the 
regular  hospital  fare  without  gastric  distress,  and  was  discharged 
in  good  condition.  Einhorn  (/.  c,  p.  313)  agrees  with  Reichmann 
as  to  the  existence  of  a  pathological  continuous  gastrosuccorrhea, 
although  he  restricts  this  name  to  cases  not  presenting  organic  lesions 
of  the  stomach.  Whenever  the  latter  exists  (lesions),  he  looks  upon 
the  accompanying  gastrosuccorrhea  as  a  consequence  of  the  main 
trouble,  but  not  as  a  cause  of  the  organic  lesion.  It  is  the  exclusion 
of  these  organic  troubles,  particularly  of  enlargements  of  the  stomach 
and  motor  insufficiency,  in  which  the  greater  curvature  has  not  de- 
scended, which  presents  so  much  difficulty.  In  all  the  cases  of 
chronic  continued  hypersecretion  that  we  have  examined  with  regard 
to  this  question,  we  were  enabled  to  discover  some  organic  lesion, 
most  frequently  an  atony,  pyloric  stenosis,  or  dilation  from  some 
cause.  After  a  careful  investigation  of  a  large  clinical  material  I 
incline  to  the  opinion  that  chronic  hypersecretion  is  in  the  majority 
of  cases  not  a  spontaneous,  idiopathic  neurosis,  but  a  secondary 
symptomatic  phenomenon.  I  base  my  conclusion  upon  the  follow- 
ing facts :  (i)  That  gastric  juice  in  amounts  varying  between  20  and 
30  c.c.  is  contained  normally  in  the  fasting  stomach  in  about  8  per 
cent,  of  cases  examined  by  myself;  the  secretion  of  the  peptic  glands 
being  set  up  by  the  presence  of  mucus,  saliva,  dust,  bacteria,  epithe- 
lia,  detritus,  etc.  (2)  That  apparently  clear  gastric  juice  obtained 
from  a  fasting  stomach  may  show  presence  of  food  particles  micro- 
scopically. (3)  That  it  is  not  possible  to  exclude  dilation  nor  ulcer 
in  all  of  these  cases,  particularly'  when  the  dilation  is  not  marked  by 
the  descent  of  the  greater  curvature.  (4)  The  liquid  obtained  from 
undoubted  dilations  of  the  stomach  may  contain  absolutely  no  food 
particles,  thus  simulating  the  condition  for  chronic  gastrosuccorrhea. 
(5)  Gastric  contents  obtained  from  dilation  of  the  stomach  do  not 
always  show  the  presence  of  products  of  imperfect  starch  digestion 
(erythrodextrin).  This  is  particularly  the  case  when  we  meet  with 
dilation  accompanied  by  hyperacidity,  but  with  a  fair  motility,  or 
where  the  peristalsis  is  only  periodically  lost.     In  any  case  of  hyper- 


840  NEUROSES   OF   SECRETION. 

acidity  it  is  possible  that  the  products  of  starch  digestion  may  be 
absent  when  very  little  carbohydrate  food  has  been  ingested.  This 
may,  of  course,  also  happen  with  gastrosuccorrhea.  (6)  In  cases  of 
typical,  so-called  chronic,  continued  supersecretion,  the  symptoms 
cease  entirely  and  the  stomach  Contains  no  gastric  juice  in  the  morn- 
ing after  the  patient  has  been  fed  by  the  rectum  for  four  to  eight  days. 
(7)  Diseases  presenting  the  classical  picture  of  Reichmann's  disease 
have  been  known  to  disappear  entirely  after  a  gastro-enterostomy  or 
a  pyloro plastic  operation  was  performed. 

S)anptomatology. — This  is  essentially  the  same  as  in  motor  in- 
sufficiency with  hyperacidity.      (See  chapter  on  this  subject.) 

The  periodic  flow  of  gastric  juice,  which  we  have  already  described 
(p.  830),  is  either  a  functional  neurosis  or  a  reflex  affection  (tabes 
dorsalis),  or  connected  with  an  affection  of  the  sympathetic.  It  is 
identical  with  the  gastroxynsis  of  Rossbach.  Possibly,  also,  the 
periodic  vomiting  of  Ley  den  belongs  to  this  group  of  neuroses.  The 
chronic  gastrosuccorrhea  is  a  symptom,  and  has  not  the  claim  to  be 
considered  a  morbid  entity  like  the  periodic  or  spasmodic  gastrosuc- 
corrhea. Chronic  flow  of  gastric  juice  may  be  a  complication  of 
ulcer  and  motor  insufficiency.  From  a  pathological  standpoint,  it  is 
well  established  that  gastritis  may  accompany  ulcer  as  well  as  dilation 
(Rokitansky,  Tebert,  Orth,  Cruveilhier) .  The  gastritis  which  accom- 
panies these  diseases,  and  which  shows  hyperacidity,  has  been  called 
by  Korczynski  and  Jaworski  ("Deutsch.  Archiv  f.  klin.  Med.,"  Bd. 
xivVii,  S.  578)  "catarrhus  acidus,"  and  by  Hayem  ("Gazette  Heb- 
dom.,"  1892,  Nos.  33  and  34)  it  has  been  designated  as  "gastrite 
hyperpeptique."  These  expressions  signify  the  same  complexity  of 
symptoms  as  those  first  described  by  Reichmann  under  the  name  of 
"gastrosuccorrhea."  The  "gastritis  acida"  of  Boas  is  quite  a  differ- 
ent thing — a  characteristic  form  of  chronic  gastritis. 

Diagnosis. — The  main  question  to  decide  is  not  whether  we  are 
dealing  with  chronic  gastrosuccorrhea,  which  is  not  very  difficult  to 
find  out,  but  to  determine  which  disease  it  is  a  consequence  of.  The 
most  frequent  causes  are  ulcer,  pylorospasm,  and  mechanical  insuffi- 
ciency. For  a  fuller  explication  of  these  subjects  and  their  conse- 
quences we  must  refer  to  the  chapters  in  which  they  are  considered. 
If  150  to  300  c.c.  of  gastric  juice  can  be  drawn  from  the  stomach  be- 
fore taking  food  in  the  morning,  which  juice  is  free  from  food  rem- 
nants, and  there  are  no  evidences  of  motor  insufficiency,  the  case  will 
be  one  of  primary  neurotic  chronic   gastrosuccorrhea.     But  if  the 


LITEJRATURE    ON    CHRONIC    GASTROSUCCORRHEA.  84 1 

food  remnants  are  very  evident  and  especially  if  organic  diseases  are 
demonstrable,  the  condition  is  secondary. 

Treatment. — If  ulcer,  pylorospasm,  or  dilation  can  be  demon- 
strated to  exist,  the  treatment  must  be  directed  to  these  fundamen- 
tal causes.  (See  Treatment  of  Ulcer  and  Motor  Insufficiency.)  In 
the  absence  of  any  definite  etiological  factor,  the  treatment  is  that 
described  under  hyperchylia.  Under  all  conditions  massage  of  the 
stomach  and  intestines,  intragastric  application  of  the  galvanic  and 
faradic  currents,  and  washing  out  of  the  stomach  are  very  essential 
adjuncts  to  treatment.  Where  there  is  much  secretion  of  gastric 
juice,  even  on  an  empty  stomach,  the  use  of  a  stomach-tube  can  not 
be  consistently  neglected.  It  is  the  only  way  to  remove  the  excess 
of  secretion  directly;  then,  again,  the  best  treatment  of  a  hyper- 
chylia is  that  which  is  supplied  directly  to  the  mucosa  in  the  form  of 
irrigations  with  calcined  magnesia,  sodium  bicarbonate,  tannin  (-j  of 
one  per  cent,  solution),  and  suspensions  of  bismuth  subnitrate.  The 
methodical  use  of  alkalies  affords  great  relief  to  the  pyrosis  and  eruc- 
tation, and  facilitates  carbohydrate  digestion.  The  alkalies  which 
we  recommend  most  strongly  are  the  magnesia  usta  and  the  ammo- 
niophosphate  of  magnesium.  Einhorn  speaks  very  favorably  of 
spraying  the  stomach  with  a  solution  of  nitrate  of  silver,  i  :  1000. 
Reichmann  administers  the  nitrate  of  silver  in  solution  or  in  gelatin 
capsules.  The  author  uses  this  salt  in  the  form  of  lavage  (i  :  looo 
and  can  speak  with  favor  of  this  treatment. 

The  diet  will  vary  with  the  underlying  causative  disease.  It  will 
be  eitfier  that  for  ulcer  or  dilation,  or  that  for  hyperchylia.  Where 
the  stomach  is  extremely  sensitive,  the  diet  orders  of  Penzoldt  may 
be  safely  tried,  because  they  are  very  sparing  and  make  little  de- 
mands upon  the  capacity  of  the  stomach.  Exclusive  rectal  feeding 
may  be  necessary ;  it  is,  as  a  rule,  promptly  followed  by  good  results. 

Dr.  D.  E-  Edsall  has  given  a  lucid  representation  of  recent  litera- 
ture on  this  subject  ("Amer.  Jour.  Med.  Sciences,"  vol.  cxvii,  1899, 
p.  694). 

LITERATURE 

ON   CHRONIC   GASTROSUCCORRHEA. 

1.  Boas,  "  Specielle  Diagnostik  u.  Therapie  d.  Magenkrankheiten,"  2.  Aufl. 

2.  Bouvetet  et  Devic,  "  La  Dyspepsia  par  Hypersecretion  Gastrique  "  (Mala- 
die  de  Reichmann),  Paris,  1892.     (Monograph.) 

3.  Cavazzani,  A.,  "  Delia  malattia  di  Reichmann  e  della  sua  c'ura,"  "  Clin. 
Med.  Ital.,"  Milan,  1898,  xxxvii. 


842  NEUROSES   OF   SECRETION. 

4.  Combemale,  "  Maladie  de  Reichmann  un  Dyspepsia  par  Hypersecretion 
Gastrique,"  "Echo  Med.  du  Nord,"  Lille,  1897,  i. 

5.  Debove  et  Remond,  "  Les  Maladies  de  rEstomac." 

6.  Faucher,  "  De  la  Crise  Aigue  dans  la  Maladie  de  Reichmann  "  (Gastrite 
Chronique  avec  Hypersecretion),  "Jour,  de  Med.  Prat.,"  25,  vi,  1897. 

7.  Hayem,  "  Resume  de  I'Anatomie  Pathologique  de  la  Gastrite  Chronique," 
"  Gaz.  Hebdom.,"  1892,  Nos.  33,  34. 

8.  Hayem,  "Ueber  Gastritis  parenchymatosa,"  "  Allgem.  Wien.  med. 
Zeitung,"  1894,  No.  2  fif. 

9.  Hayem,  "  Stenose  incomplete  du  Pylore,  Pretendue  Maladie  de  Reich- 
mann," "  Presse  Medicale,"  31  Mars,  1897. 

10.  Jaworski,  "  Zeitschr.  f.  klin.  Med.,"  Bd.  xi.  Heft  2  u.  3;  "  Miinch.  med. 
Wochenschr.,"  1887,  Nr.  7  u.  8  ;  "  Wien.  med.  Presse,"  1886,  Nr.  52  ;  "  Wien. 
med.  Wochenschr.,"  1887,  Nr.  49  u.  f. 

11.  Johnson,  E.  E.,  "  Miinch.  med.  Wochenschr.,"  1887,  Nr.  48  u.  f. 

12.  Johnson  und  Behm  ("Zeitschr.  f.  klin.  Med.,"  Bd.  xxii,  S.  478),  "Re- 
port of  106  Cases  of  Supersecretion,"  including  all  cases  where  slight  amounts 
of  gastric  juice  were  found,  and  give  complete  literature. 

13.  V.  Korczynski  und  Jaworski,  "  Deutsches  Archiv  f.  klin.  Med.,"  Bd. 
XLVii,  S.  578. 

14.  Leyden,  "Zeitschr.  f.  klin.  Med.,"  1882,  Bd.  vi,  S.  605. 

15.  Linossier,  "Maladie  de  Reichmann  et  Stenose  Pylorique,"  "  Semaine 
Med.,"  Paris,  1898,  xviii. 

16.  Lyon,  G.,  "  L'Analyse  du  sue  Gastrique,"  Paris,  1890. 

17.  Lyon,  G.,  "  Les  Theories  Nouvelles  sur  la  Gastrosuccorrhee  ou  Maladie 
de  Reichmann  et  sou  Traitement,"  "Rev.  de  Therap.  Med.  et  Chir.,"  Paris, 
1897,  LXIV. 

18.  Martius,  F.,  "  Ueber  den  Inhalt  des  gesunden,  niichternen  Magens  und 
den  continuirlichen  Magensaftfluss,"  "Deutsche  med.  Wochenschr.,"  1894, 
Nr.  32. 

19.  Morano,  G.,  "  Malattia  di  Reichmann,"  "  Riforma  Med.,"  Napoli,  1898, 
XIV,  pt.  4. 

20.  Reichmann,  "  Berl.  klin.  Wochenschr.,"  1892,  Nr.  40;  1884,  Nr.  48  ; 
1887,  Nr.  12  u.  f. ;  1887,  Nr.  14. 

21.  Riegel,  "Zeitschr.  f.  klin.  Med.,"  Bd.  xi  u.  xii ;  "Miinch.  med.  Woch- 
enschr.," 1884,  Nr.  45  u.  46;  "Deutsche  med.  Wochenschr.,"  1887,  Nr.  29; 
1892,  Nr.  21  ;  1893,  Nr.  30  u.  31  ;  "  Volkmann's  Samml.  klin.  Vortrage,"  1886, 
S.  289. 

22.  Rosin,  "Ueber  das  Secret  des  niichternen  Magens,"  "Deutsche  med. 
Wochenschr.,"  1893,  Nr.  30. 

23.  Rossbach,  "  Deutsches  Archiv  f.  klin.  Med.,"  1885,  Bd.  xxxv. 

24.  Roux,  "  Le  Syndrome  de  Reichmann,  Expose  Critique  des  Travaux 
Recents  sur  I'Hypersecretion  Chlorhydrique  Continue,"  "  Gaz.  des  Hopit.," 
No.  61,  1897. 

25.  Saupault,  "Sur  un  cas  de  Gastrosuccorrhee,"  "Gaz.  Hebd.  de  Paris," 
27  Janvier,  1897. 

26.  Schreiber,  Jul.,  "  Gastrektasie  u.  deren  Verhaltniss  z.  chronischen  Hyper- 
secretion," "Archiv  f.  Verdauungskrankh.,"  Bd.  II,  S.  423. 

27.  Schreiber,  Jul.,  "Ueber  den  continuirlichen  Magensaftfluss"  (Secretio 
hydrochlorica  continua),  "Deutsche  med.  Wochenschr.,"    1893,  Nr.  29  u.  30; 


SUBACIDITY.  843 

ibid.,  "  Ueber  continuirlichen  Magensaftfluss,"  "  Deutsche  med.  Wochenschr.," 
1894,  Nr.  18,  20,  u.  21. 

28.  Sticker,  "  Milnch.  med.  Wochenschr.,"  1886,  Nr.  32  u.  33. 

29.  Strubing,  "  Zeitschr.  f.  klin.  Med.,"  1885,  Bd,  ix,  S.  381. 

30.  Vente,  A.,  Inaug. -Dissert.,  Giessen,  1890. 

31.  Wolff,  "Zeitschr.  f.  klin.  Med.,"  Bd.  xvi. 

32.  Text-books  of  Leube,   Riegel,   Boas,  Ewald,  Debove  et  Remond,  Bou- 
veret,  Penzoldt,  Fleiner,  S.  Martin,  A.  Pick,  Mathieu,  Einhorn. 

33.  Edsall,  D.  L.,  "  Amer.  Jour.  Med.  Sciences,"  vol.  cxvii,  1899,  p.  695. 


SUBACIDITY  (HvpoCHLORHYDRiA  OR  Hypochylia). 
Subacidity,  as  a  neurosis,  is  a  disease  in  which,  even  during  the 
height  of  digestion,  gastric  juice  is  secreted  in  which  the  HCl,  and 
with  it  the  pepsin  and  rennin,  are  present  in  smaller  amounts  than 
normal.  We  will  not  consider  under  this  head  those  secretory 
anomalies  in  which  the  secretion  of  gastric  juice  is  absent  entirely. 
These  states  will  be  considered  under  Achylia  Gastrica,  or  Inacidity. 
In  subacidity  HCl  is  still  secreted,  but  in  such  small  amounts  that  it 
enters  into  combination  with  albuminous  foods  entirely,  and  we  can 
detect  it  only  as  combined  HCl.  Cases  in  which  free  HCl  can  be 
detected  by  Congo  paper  after  our  double  test-meal  do  not  logically 
belong  in  this  class  of  subacidity,  because  the  presence  of  free  HCl 
means  that  more  HCl  is  secreted  than  can  enter  into  combination 
with  the  food;  there  is  an  excess  of  acid  beyond  that  required  for 
digestion.  Technically,  we  may,  therefore,  define  hypochylia  as  a 
secretory  neurosis  in  which  free  HCl  is  absent  at  the  test-meal,  but 
combined  HCl  and  the  ferments  are  still  present.  Nervous  hypo- 
chylia is  in  reality  but  a  phase  of  nervous  dyspepsia,  or  neurasthenia 
gastrica.  But,  as  it  is  desirable  to  represent  all  secretory  neuroses 
seriatim,  we  have  here  abstracted  the  symptoms  of  nervous  depres- 
sion of  gastric  secretion.  It  was  formerly  believed  that  subacidity 
was  always  connected  with  some  organic  gastric  disease  (carcinoma, 
gastritis),  or  occurred  in  the  train  of  infectious  diseases,  or,  as  a  result, 
with  anemia  and  leukemia.  Subacidity,  however,  may  exist  on  a 
purely  nervous  substratum,  in  hysteria  and  neurasthenia,  and  in 
psychoses.  It  then  occurs,  independently  of  anatomical  changes 
in  the  stomach,  as  a  functional  disturbance  of  the  secretory  nerves, 
the  irritability  of  which  has  been  reduced.  Functional  disturbances 
of  this  character  may  be  limited  to  the  secretory  nerves  and  not  in- 
volve the  remaining  nervous  apparatus  of  the  stomach.  The  amount 
of  HCl  secreted  is  not  sufficient  to  saturate  the  albumin  present  in  the 


844  NEUROSES   OF   SECRETION. 

proteid  food:  in  other  words,  an  HCl  deficit  exists.  It  is  probable 
that  the  secretor}^  nerves  become  exhausted  sooner  than  the  motor 
nerves,  and  that,  therefore,  subacidity  may  be  an  expression  of  ex- 
haustion or  weakness  in  the  secretory  apparatus.  In  this  way  we 
have  repeated!}'  observed  prolonged  subacidit}^  followed  by  pro- 
nounced h^^peracidity. 

Etiology. — Nerv^ous  subacidity  or  hypochylia  is  a  secondary 
phenomenon  occurring  with  neurasthenia,  hysteria,  tabes,  and  the 
psychoses. 

Symptomatology. — ^^'hen  the  motor  function  of  the  stomach  is 
good,  symptoms  may  be  absent  entirely,  but  the  slightest  insuffi- 
ciency of  the  motor  power  is  rapidty  followed  by  decomposition  in 
the  gastric  contents,  caused  by  bacteria,  for  the  amount  of  HCl 
secreted  is  not  sufficient  to  inhibit  or  prevent  the  action  of  micro- 
organisms. As  a  consequence  of  this  organic  acids  are  formed,  and 
gaseous  formations  create  gastric  discomfort,  and,  at  times,  intes- 
tinal distention.  There  is  nothing  characteristic  in  the  sympto- 
matology of  subacidity.  The  result  of  the  depressed  state  of  the 
secretion  and  the  general  symptomatology  are  the  same  as  those 
in  achylia  gastrica,  and  will  be  described  under  that  heading.  It 
is  natural  that  am^dolysis  should  proceed  more  rapidly  in  the  absence 
of  free  HCl,  since  nothing  can  disturb  the  activity  of  the  ptyalin  in 
that  case.  On  the  other  hand,  the  digestion  of  meats,  eggs,  etc., 
is  most  unsatisfactory'.  As  HCl  is  one  of  the  principal  normal  stimu- 
lants to  peristalsis,  the  disease  is  frequently  accompanied  by  consti- 
pation, which,  in  turn,  produces  increasing  putrefaction  of  the  intes- 
tinal contents,  being  in  this  case  more  pronounced  because  the  dis- 
infecting action  of  the  HCl  is  missing. 

Differential  Diagnosis. — Carcinoma  and  chronic  gastritis  might 
be  confounded  in  the  incipient  stages  with  nervous  subacidity  (for 
the  differential  diagnosis  from  carcinoma  and  gastritis,  we  refer  to 
the  chapters  on  these  diseases) ;  but  when  the  enzymes,  pepsin  and 
rennin,  can  be  demonstrated  in  the  gastric  contents,  or  even  if  only 
the  proenz5^mes,  pepsinogen  and  rennin-zymogen,  can  be  demon- 
strated, one  can  not,  as  a  rule,  exclude  chronic  gastritis  and  carci- 
noma. A  patient  and  prolonged  study  of  nervous  subacidity  will  not 
fail  to  demonstrate  that  great  variations  exist  in  the  amount  of 
hydrochloric  acid  that  is  secreted.  Occasionally  it  may  be  found 
that  a  transition  to  a  normal  acidity,  or  even  to  hyperchylia,  has 
taken  place.     Lactic  acid  is  a  verv  rare  occurrence  in  nervous  sub- 


TREATMENT  AND   DIET  IN   SUBACIDITY.  845 

acidity;  its  presence  and  the  Oppler-Boas  bacillus  would  speak  for 
carcinoma. 

Treatment. — In  most  cases  it  will  be  sufficient  to  supply  an 
amount  of  dilute  HCl  which  is  commensurate  with  the  deficit.  In 
rare  instances  it  will  be  impossible  to  administer  sufficient  HCl  to 
give  the  reaction  for  free  HCl,  because  it  is  not  well  tolerated  in  this 
quantity.  In  that  case  we  advise  adding  the  HCl  to  beef-juice, 
either  Wyeth's,  Valentine's,  or  the  Mosquera  beef-jelly.  This  makes 
a  sauce  which  can  be  poured  over  the  finely  divided  meat  foods  that 
are  to  be  eaten.  The  meat-dissolving  power  of  the  acid  is  not  de- 
stroyed by  this  method  of  preparing  it,  although  the  acid  may  be 
partly  in  a  combined  state.  Abnormal  fermentations  and  decompo- 
sitions are  rare,  and  therefore  the  stomach-tube  can,  as  a  rule,  be 
dispensed  with.  The  bitter  tonics — quassia,  cinchona,  calumbo, 
gentian — and  the  basic  orexin  (in  five-grain  doses  three  times  a  day) 
very  often  increase  the  appetite  and  favor  a  secretion  of  HCl.  Strych- 
nin and  the  intragastric  use  of  the  faradic  current  we  warmly  recom- 
mend for  this  purpose.  Pilocarpin,  according  to  Riegel,  increases 
the  secretion  of  gastric  juice,  but  in  my  experience  it  is  too  dangerous 
a  drug  to  use  with  that  persistence  that  is  requisite  in  these  cases. 
When  the  motility  is  good,  those  mineral  waters  which  are  rich  in  so- 
dium chlorid  are  worth  a  trial.      (See  section  on  Mineral  Waters.) 

The  Diet. — It  is  an  interesting  fact  that  patients  with  subacidity 
instinctively  avoid  a  meat  diet,  and  are  large  carbohydrate  eaters. 
It  is  well,  however,  not  to  let  them  persist  on  the  exclusive  use  of 
carbohydrates,  but  to  train  up  the  digestive  capacity  of  the  stomach 
to  a  more  abundant  digestion  of  proteids.  All  meats  should  be  given 
in  a  finely  divided  state.  The  extractive  materials  in  meat  are  use- 
ful stimulants  to  appetite  (Pawlow).  Before  the  meal,  it  is  well  to 
stimulate  the  appetite  and  secretion  by  giving  a  few  sardels  or  the 
roe  of  potted  herring,  or,  what  is  more  palatable  and  easier  to  pro- 
cure, a  sandwich  spread  with  Russian  caviar.  Surf-baths,  cold 
sponge-baths  at  home,  proper  movements  of  the  bowels,  and  at  least 
eight  to  nine  hours  of  sleep,  are  indispensable  agents  in  the  manage- 
ment of  this  secretory  defect. 


846  ACHYLIA  GASTRICA. 


CHAPTER  XIII. 
ACHYLIA  GASTRICA. 

Synonyms. — Absence  of  the  Secretion  of  Gastric  Juice ;  Nervous  Inacidity ; 
Atrophy  of  the  Stomach ;  Anadenia  Ventriculi ;  Phthisis  Ventriculi ; 
Achlorhydria. 

Nature  and  Concept. — The  term  achylia  gastrica  means,  liter- 
ally, without  gastric  chyle,  and  was  first  proposed  by  Einhorn 
("New  York  Medical  Record,"  June  11,  1892)  to  designate  a  class 
of  diseases  in  which  no  gastric  juice  is  secreted. 

The  affection  is  found  to  exist  in  two  varieties — first,  the  pri- 
mary, idiopathic,  possibly  inherited,  achylia ;  secondly,  the  acquired 
or  secondary  achylia.  The  primary  idiopathic  or  symptomatic 
achylia  is  characterized  by  the  fact  that  absence  of  secretion  is  evi- 
dent before  any  marked  anatomical  changes  have  occurred  in  the 
mucosa  which  could  explain  the  loss  of  function.  It  is,  therefore, 
as  a  rule,  not  regarded  as  a  result  acquired  from  a  real  disease,  but 
as  an  individual  peculiarity,  possibly  an  inherited  functional  debility. 
There  are  undoubtedly  persons  in  whom  gastric  secretion  may  be 
absent  for  years,  or  permanently  wanting;  yet  who,  apparently, 
may  enjoy  robust  health.  The  majority  of  these  individuals,  how- 
ever, have  suffered  from  frequent  dyspeptic  complaints,  which  are 
partly  of  a  purely  nervous  character.  In  these  cases  severe  anemic 
and  cachectic  conditions  are  usually  absent,  and  while  the  general 
nutrition  may  occasionall}^  be  found  disturbed,  it  is  easily  remedied 
with  proper  dietetic  treatment. 

The  last-named  type  of  cases  demonstrates  that  the  function  of 
the  stomach  may  be  permanently  lost,  so  far  as  its  digestive  power 
is  concerned,  yet  with  no  apparent  effects  upon  the  general  con- 
stitution. A  very  convincing  argument  for  the  compensatory  diges- 
tive power  of  the  intestine!  Tubarsch  ("Achylia  Gastrica,"  etc., 
von  Martins  u.  Tubarsch,  1897,  p.  74)  raises  the  question  whether 
gastric  digestion  may  not  be  entirely  dispensed  with,  or  whether  it  is 
not  superfluous,  which  of  course  implies  that  the  secretion  of  HCl 
may  possibly  be  an  unnecessary  function.  There  can  be  no  doubt, 
however,  that  deficiency  of  gastric  secretion  is  a  disease.  Individuals 
affected  with  symptomatic  achylia  are  very  much  more  sensitive  in 


NATURE   OF   ACHYLIA.  847 

general,  and  more  susceptible  to  gastric  diseases,  than  their  fellow- 
men  equipped  with  normal  stomachs.  The  idea  that  gastric  diges- 
tion is  superfluous  and  dispensable  impresses  us  as  being  a  reactive 
opinion  induced  by  the  other  extreme  view  formerly  held,  according 
to  which  the  stomach  was  the  most  important  of  all  digestive  organs. 
Gastric  secretion  is  by  no  means  a  useless  function.  lyubarsch  says : 
"Those  who  have  lost  it,  have  one  weapon  less  in  the  struggle  for 
existence,"  and  clinical  experience  teaches  that  persons  who  have  no 
secretion  of  gastric  juice  are  much  more  liable  to  diseases  of  the  stom- 
ach. When  such  are  attacked  by  intestinal  diseases  and  this  supple- 
mentary digestion  is  interfered  with,  the  prognosis  becomes  serious. 

Achylia  may  exist  upon  a  nervous  basis,  it  may  be  congenital  or 
acquired,  in  consequence  of  some  organic  gastric  disease. 

The  results  of  the  examination  of  the  gastric  contents,  in  simple, 
uncomplicated  achylia,  are  quite  characteristic:  The  fasting  stom- 
ach, examined  in  the  morning  before  any  food  has  been  taken,  is 
empty.  I  have  never  been  able  to  obtain  more  than  twenty  to  thirty 
cubic  centimeters  of  neutral,  slightly  mucoid  liquid;  remnants  of 
ingesta  of  the  previous  day  are  never  observed.  One  hour  after  the 
Ewald  test-breakfast  the  contents  of  the  stomach  have  the  same 
appearance  as  they  have  in  the  mouth  before  they  are  swallowed. 
This  appearance  is  claimed  by  Einhorn  and  others  to  be  quite  char- 
acteristic. Contents  drawn  in  this  manner  are  generally  slightly 
acid.  Blue  litmus  paper  is  very  slightly  reddened.  The  total  acidity 
varied  in  our  cases  from  two  to  eight.  This  degree  of  acidity  can  be 
found  in  the  test-meal  before  it  is  eaten.  Whenever  the  acidity  of 
the  drawn  stomach-contents  does  not  exceed  that  of  the  meal  before 
it  is  swallowed,  it  may  be  safely  assumed  that  free  and  combined 
HCl  is  absent ;  in  other  words,  no  HCl  has  been  secreted.  Whenever 
the  total  acidity  is  equal  to  four  only,  it  is  due  to  acid  that  has  been 
introduced  in  the  food ;  with  a  total  acidity  no  higher  than  four,  one 
hour  after  a  test-breakfast,  it  is,  therefore,  unnecessary  to  make 
further  analyses  for  the  detection  of  HCl.  The  gastric  contents, 
when  filtered  and  mixed  with  HCl  sufficient  to  produce  the  reaction 
with  Congo  paper,  can  not  digest  discs  of  egg-albumen. 

Milk  taken  by  achylic  patients  may  be  drawn  out  twenty  or  thirty 
minutes  afterward  perfectly  unchanged,  or,  rather,  uncoagulated. 
The  secretion  of  pepsin  and  rennin  is,  therefore,  absent.  By  proper 
tests  it  can  also  be  found  that  pepsinogen  and  rennin- ZA^mogen  are 
also  wanting.     Lubarsch  and  Martins  assert  that  the  isolated  loss  of 


848  ACHYLIA   GASTRICA. 

HCl,  without  loss  of  secretion  of  pepsin  and  rennin,  does  not  exist; 
and  for  these  cases  of  loss  of  gastric  secretion  (not  the  HCl  simply, 
but  all  the  constituents  of  gastric  juice)  the  terms  anacidity,  inacid- 
ity,  and  achlorhydria  are  not  so  expressive  and  logical  as  the  desig- 
nation "achylia  gastrica."  We  may  assert,  however,  on  a  very  large 
personal  experience,  that  isolated  loss  of  HCl  secretion  and  preserva- 
tion of  formation  of  ferments  does  occur.  In  the  progressive  de- 
struction of  the  mucosa  accompanying  carcinoma  and  gastritis  there 
are  stages  in  which  HCl  is  totally  wanting,  and  yet,  by  proper 
methods,  secretion  of  enzymes,  or  of  the  proenzymes,  can  be  detected. 
All  other  cases  of  loss  of  secretion  not  due  to  carcinoma  or  atrophic 
gastritis  may  logically  be  classed  as  achylia.  A  further  pronounced 
sign  of  achylia  is  the  abnormally  small  quantity  of  gastric  contents 
found  one  hour  after  the  test-breakfast.  Biedert  ("Diatetik  u. 
Kochbuch,"  etc.,  1895),  who  suffers  from  this  affection  himself, 
found  that  his  stomach  was  very  rapidly  emptied,  so  that  he  had  to 
draw  the  contents  within  forty -five  minutes  if  he  wished  to  obtain 
any  at  all. 

Julius  Miller  (/.  c,  "Archiv  f.  Verdauungskrankh.,"  Bd.  i,  p.  233) 
found  that  strong  solutions  of  sodium  chlorid  are  very  much  diluted 
when  they  are  brought  into  the  human  stomach.  It  is  further 
known  that  strong  solutions  of  common  salt,  when  brought  into  the 
stomach,  arrest  HCl  secretion.  The  tendency  to  dilute  solutions  that 
are  put  into  the  stomach  is  so  persistent  that  it  continues  even  after 
the  concentration  of  these  solutions  has  inhibited  the  HCl  secretion. 
Alcohol,  various  forms  of  sugar,  dextrin,  and  peptone  are  absorbed, 
and  a  more  or  less  active  excretion  of  water  goes  on  hand  in  hand  and 
simultaneously  with  such  absorption.  In  achylia  gastrica,  however, 
the  stomach  differs  very  much  in  this  respect  from  the  normal  organ, 
since  it  has  then  lost  its  power  of  diluting  the  gastric  contents. 

The  fact  that  concentrated  solutions  of  sodium  chlorid  inhibit 
the  secretion  of  HCl  has  been  made  available  in  the  treatment  of 
hyperacidity.  From  this  fact  it  is  very  probable  that,  in  achylia, 
we  are  dealing  not  only  with  loss  of  the  characteristic  secretion,  the 
gastric  juice  with  its  HCl  and  ferments,  but  also  that  there  seems  to 
be  no  secretion  of  any  kind  issuing  from  the  mucosa.  The  diluting 
secretion  of  the  stomach  is,  under  normal  conditions,  not  exclusively 
made  up  of  the  normal  gastric  juice,  and  we  are  here  confronted 
with  a  physiological  function  of  a  very  complicated  character,  con- 
cerning which  very  little  of  a  positive  nature  is  known.     There  is  a 


GASTRIC    ATROPHY   WITH    ANEMIA.  849 

general  consensus  of  opinion,  which  we  can  confirm,  that  in  ach5i'lia 
there  is  an  exceptionally  great  vulnerability  of  the  mucosa.  It  is  a 
frequent  experience  with  achylic  patients  to  find  that  particles  of  the 
mucosa  showing  slight  hemorrhages  are  unintentionally  scraped  or 
torn  off  during  the  drawing  of  the  test-meals. 

Lubarsch  (l.  c),  Einhorn  (/.  c),  Biedert  (/.  c),  Cohnheim  ("Archiv 
f.  Verdauungskrankh.,"  Bd.  i,  p.  274),  Jaworski  ("Miinch.  med. 
Wochenschr.,"  1887,  Nr.  7  und  8),  have  observed  this  phenomenon, 
and  the  first-mentioned  author  asserts  that  the  vulnerability  of  the 
mucosa  in  achylia  is  as  great  as  in  carcinoma.  In  achylia  it  is  almost 
impossible  to  avoid  the  scraping  off  of  portions  of  the  superficial 
mucous  membrane,  no  matter  what  shaped  tube  is  used,  and  if  it  is 
desired  to  avoid  scraping  the  mucosa  at  all,  it  is  safer  to  use  a  tube 
which  is  entirely  closed  at  its  lowxr  end  and  has  but  one  velvet  eye- 
opening  at  the  side  (Tiemann  &  Co.,  New  York).  Scraping  off  of 
minute  particles  is  a  harmless  procedure,  but  the  tearing  of  larger 
pieces  by  suction  may  be  followed  by  extensive  hemorrhages. 

Total  loss  of  gastric  secretion,  even  as  a  consequence  of  a  fully 
developed  atrophy  of  the  mucosa  (anadenia),  can  not  cause  anemia 
or  cachexia  per  se.  Those  cases  in  which  anemia  has  been  observed 
in  connection  with  achylia  were  most  probably  complicated  by  a 
mechanical  insufficiency  of  the  stomach,  or  by  other  diseases;  thus, 
in  some  cases,  syphilis  or  tuberculosis,  and  extension  of  the  atrophic 
process  to  the  mucosa  of  the  intestine,  have  complicated  the  gastric 
derangement. 

The  credit  of  having  first  pointed  out  the  association  of  gastric 
atrophy  with  anemia  is  usually  attributed  to  S.  Fenwick  (lecture  on 
"  Atrophy  of  the  Stomach,"  "The  Lancet,"  July  7,  1877;  also  "  On 
Atrophy  of  the  Stomach  and  Certain  Nervous  Affections  of  the  Diges- 
tive Organs,"  London,  1880,  J.  &  A.  Churchill).  Both  Einhorn 
(Z.  c,  p.  321)  and  Martins  (I.  c,  p.  16)  assert  that  Fenwick's  report  is 
the  pioneer  observation  on  this  subject.  As  a  matter  of  fact,  it  was 
our  countryman,  Austin  Flint,  who  first  called  attention  to  the  rela- 
tion between  anemia  and  atrophy  of  the  gastric  glands  (Austin  Flint, 
"The  American  Medical  Times,"  i860).  He  expressed  the  opinion 
that  some  cases  of  profound  anemia  are  dependent  upon  atroph}^  of 
the  glands  of  the  stomach.  (The  further  contributions  of  Flint  to 
this  subject  are  to  be  found  in  the  "New  York  Med.  Jour."  for  March, 
1871,  and  in  his  "Principles  and  Practice  of  Medicine,"  p.  477,  Phila- 
delphia,   1 881.)     The    priority    of    Flint's    publications   have   been 


850  ACHYLIA   GASTRICA. 

emphasized  by  Professor  William  H.  Welch  ("A  System  of  Medicine 
by  American  Authors,"  vol.  11,  p.  616*). 

Although  the  anemia  which  supervenes  in  these  cases  of  achylia 
can  not  be  directly  ascribed  to  the  gastric  atrophy,  and  too  much 
importance  was  attributed  by  Flint  and  others  to  the  state  of  the 
gastric  mucosa,  the  reports  of  this  author  are,  nevertheless,  very 
valuable,  because  the  secondary  states,  which  we  have  mentioned  as 
really  causing  the  anemia  and  cachexia,  are  most  probably  brought 
about  by,  and  owe  their  origin  to,  the  primary  degenerative  changes 
in  the  gastric  mucosa  which  Flint  and  Osier  have  described. 

In  the  first  part  of  this  work  I  have  reported  examinations  of 
fragments  of  mucosa  derived  from  twelve  cases  of  anacidity  or  sub- 
acidity;  of  these,  ten  were  cases  of  typical  achylia  gastrica.  In 
these  twelve  cases  proliferation  of  glands,  with  marked  round-cell 
infiltration,  was  found  once.  The  fragment  was  apparently  normal 
in  two  cases,  but  of  the  ten  cases  of  typical  achylia,  granular  gastritis 
and  atrophy  of  the  mucosa  could  be  established  in  nine.  In  making 
the  diagnosis  of  simple  achylia  gastrica  we  excluded  all  those  cases  of 
permanent  loss  of  secretion  evidently  due  to  carcinoma  or  pronounced 
chronic  atrophic  gastritis.  In  fact,  before  making  these  detailed 
examinations,  I  supposed  it  was  possible  that  this  form  of  achylia 
existed  simply  as  a  neurosis,  because  all  of  the  ten  cases  which  we 
described  occurred  in  neuropathic  patients.  I  had  also  inclined  to 
Einhorn's  view,  that  some  forms  of  achylia  might  be  of  purely  ner- 
vous origin.  We  have  since  then  examined  a  number  of  new  cases  in 
addition  to  those  reported,  making  in  all  fourteen.  In  none  was  the 
mucosa  found  perfectly  normal.  It  seems  improbable  that  a  per- 
manent cessation  of  a  normal  function  could  be  caused  by  a  neu- 
rasthenic condition.  This  explanation  of  achylia  would  be  justifiable 
only  in  case  we  could  demonstrate  that  in  this  affection  the  gastric 
mucosa  was  perfectly  normal.  To  our  knowledge,  there  is  no  case 
of  well-authenticated  achylia  on  record  in  which  a  cure  or  an  improve- 

*  Since  Flint's  publications,  cases  have  been  reported  by  Quincke,  Brabazon,  Noth- 
nagel,  Rosenheim,  and  G.  Meyer.  The  purely  American  contributions  to  this  subject 
are  very  valuable.  They  have  been  made  by  Henry  and  Osier  ("  Atrophy  of  the  Stom- 
ach, with  Clinical  Features  of  Progressive  Pernicious  Anemia,"  "  Amer.  Jour.  Med. 
Sciences,"  April,  1887)  ;  F.  P.  Kinnicutt  ("  Atrophy  of  the  Gastric  Tubules:  Its  Rela- 
tion to  Pernicious  Anemia,"  "Amer.  Jour.  Med.  Sciences,"  vol.  xciv,  p.  419,  1887) ; 
Allen  Jones  ("Gastric  Anacidity,"  "  New^  York  Med.  Jour.,"  p.  573,  May,  1893); 
D.  D.  Stevi^artC' Amer.  Jour.  Med.  Sciences,"  Nov.,  1895);  Einhorn  ("  Med.  Record," 
June  II,  1892)  ;  also  in  Boas'  "Archives  of  Digestive  Diseases,"  vol.  i,  p.  158. 


ACHYLIA   GASTRICA   AS   A    CAUSE)    OF    NEURASTHENIA.  85 1 

ment  in  the  neurasthenia  was  reported  to  have  cured  or  improved 
the  secretory  defect. 

There  are,  no  doubt,  highly  nervous  patients  who  secrete  HCl 
normally,  but  under  the  influence  of  the  nervous  excitement  and 
apprehension  coincident  with  the  drawing  of  the  test-meal,  the  gas- 
tric secretion  is  temporarily  inhibited.  I  have  seen  three  such  cases 
in  which  I  could  not  detect  HCl  at  six  consecutive  analyses,  but  a 
normal  secretion  was  found  in  the  vomited  matter  brought  up  by 
the  patient  at  home.  Later,  the  secretion  was  also  found  normal 
in  the  test-meals  drawn  at  my  office.  The  question  has  also  sug- 
gested itself,  whether  achylia  gastrica  could  not  be  the  cause  of  the 
neurasthenia.  Nor  on  this  point  are  there  any  authenticated  ob- 
servations. Experience  has  taught,  however,  that  neurasthenic 
disturbances  disappear  in  these  cases  with  an  improvement  of  the 
general  condition,  while  the  achylia  continues,  which  would  not  be 
the  case  were  the  latter  the  cause  of  the  neurasthenia.  The  loss  of 
function  in  this  disease  is  not  a  relative  or  transient  one,  but  it  is 
absolute  and  permanent.  Biedert  {I.  c,  p.  173)  gives  it  as  his  opinion 
that  the  persistent  loss  of  HCl  and  ferments  gives  the  impression  of  a 
lasting  defect,  not  of  a  variable  increasing  or  decreasing  inhibition. 
The  absence  of  the  gastric  secretion  is  the  same,  whether  the  patients 
are  very  much  run  down  and  emaciated  and  subject  to  much  suffer- 
ing or  whether  they  are  in  a  state  of  good  health.  The  supposition 
of  Biedert  that  there  may  be  a  great  many  who  possess  this  defect 
and  are  unaware  of  it,  has  been  verified  by  a  number  of  observations 
among  the  students  at  my  clinic.  While  studying  the  question 
whether  the  normal  healthy  stomach  contained  digestive  juice  in  the 
fasting  condition,  we  discovered  an  athletic,  robust  student  who  had 
no  HCl  whatever  in  his  stomach,  whether  fasting  or  after  meals. 
The  total  acidity,  taken  after  test-meals  on  six  different  occasions, 
varied  between  one  and  four;  as  these  analyses  were  made  shortly 
before  the  examinations  for  the  degree  of  M.D.,  we  did  not  inform 
the  candidate  of  the  physiological  defect  in  his  stomach,  fearing 
that  it  might  cause  him  some  mental  annoyance,  and  for  all  that  we 
know  he  may  still  be  unaware  of  his  achylia  and  continue  in  vigorous 
health.  My  results  concerning  the  condition  of  the  gastric  mucous 
membrane  are  in  accordance  with  those  of  Cohnheim  (/.  c),  Einhorn 
("N.  Y.  Med.  Record,"  June  27,  1896),  Hayem  ("Allgem.  Wiener 
med.  Zeitung,"  1894,  Nr.  2-17),  and  have  recently  been  supported 
by  Martins  and  Lubarsch  ("Achylia  Gastrica,"  pp.  1 12-170),  and 
56 


852  ACHYLIA   GASTRICA. 

H.  Strauss  ("Virchow's  Archiv,"  Bd.  Cliv).  The  results  of  the  very 
exact  investigations  of  these  last  authors  make  it  probable  that  a 
more  or  less  pronounced  granular  gastritis  exists  in  the  majority  of 
cases  of  achylia. 

The  anatomical  changes,  however,  are  not,  in  all  cases,  sufficiently 
advanced  to  explain  the  permanent  loss  of  function.  There  is  no 
indication  at  present  for  determining  whether  glandular  gastritis  is 
the  cause  or  result  of  achylia.  It  is  self-evident  that  a  weak  gastric 
parenchyma  should  be  less  resistant  to  exterior  detrimental  influ- 
ences— such  as  bacterial  invasion — than  a  robust  gastric  tissue. 
The  secretion  of  HCl  being  the  normal  disinfectant,  though  not  an 
absolute  antiseptic,  it  largely  protects  the  mucosa  from  infection. 

It  is  evident  from  what  has  been  said  in  the  etiology  of  the  various 
diseases  of  the  stomach  that  the  organ  is  exposed  to  many  external 
aggressions  of  a  thermic,  chemical,  mechanical,  and  bacterial  nature, 
and  it  is  a  matter  of  astonishment  what  intense  maltreatment  a 
healthy  stomach  will  endure  without  reacting  pathologically.  It  is, 
therefore,  conceivable  that  the  anatomical  loss  of  the  glandular  appa- 
ratus will  render  those  individuals  afflicted  with  primary  simple 
achylia  more  susceptible  to  bacterial  invasion.  Most  observers 
agree  that  the  increased  vulnerability  of  the  mucosa  goes  hand  in 
hand  with  the  loss  of  secretion ;  this  lessens  the  power  of  resistance, 
and  eventually  induces  a  state  of  chronic  granular  gastritis,  effected 
by  causes  which  a  healthy  stomach  would  resist  without  any  change. 

Symptoms. — The  disturbances  of  function  may  long  remain  latent. 
Persons  with  achylia  may  for  many  years  have  no  subjective  or  objec- 
tive disturbances  of  any  kind;  but  sooner  or  later  dyspeptic  com- 
plaints arise.  The  subjective  sensations  are  not  characteristic, 
but  are  essentially  those  of  nervous  dyspepsia,  accompanied  by 
eructation,  fullness,  and  pressure  after  eating,  gradually  leading  to 
attacks  of  severe  gastralgia.  The  symptomatology,  as  based  upon 
the  complaints  of  the  patient,  is  most  accentuated  in  neurasthenics. 
In  persons  with  a  perfectly  sound  nervous  system  achylia  may  exist, 
and  the  individual  may  be  unaware  of  it ;  this  is  proved  by  the  case 
of  the  medical  student  reported  in  the  preceding.  Oppler  (' '  Deutsche 
med.  Wochenschr.,"  1896,  Nr.  32,  S.  511)  has  reported  a  number  of 
cases  which  make  it  probable  that  loss  of  gastric  secretion  predisposes 
to  diarrhea  and  intestinal  catarrhs,  which  are  not  benefited  until  the 
achylia  is  discovered,  when  rational  treatment  effects  improvement. 
The  personal  description  which  Professor  Biedert  (/.  c.)  gives  of  his 


SYMPTOMS    OF   ACHYLIA   GASTRICA.  .  853 

own  case  is  a  weighty  argument  pointing  to  the  fact  that  achyHc 
patients  are  very  much  predisposed  to  diarrhea.  Among  the  achyhc 
patients  which  I  have  studied  (fourteen  in  all),  I  observed  attacks  of 
diarrhea  in  five.  So  far  as  I  could  determine,  the  colon  and  the 
duodenum  were  in  normal  condition.  I  also  studied  the  state  of  the 
duodenum  by  my  method  of  duodenal  intubation,  showing  the  pan- 
creatic and  hepatic  secretions  to  be  normal.  This  makes  it  probable 
that  these  diarrheas  are  possibly  not  due  to  an  extension  of  the  ana- 
tomical changes  in  the  stomach  to  the  intestine,  but  to  fermentative 
processes,  developed  in  the  absence  of  HCl  secretion.  These  diar- 
rheas confirm  Bunge's  view  that  at  least  one  effect  of  the  HCl  secre- 
tion is  that  of  a  partial  antiseptic. 

Martins'  conclusions  {I.  c,  p.  loi)  are  the  following:  Achylia  gas- 
trica  is  due  to  two  conditions:  (i)  a  primary  secretory  debility  of 
the  stomach,  constituting  simple  achylia  gastrica ;  (2)  atrophy  of  the 
gastric  mucosa  (anadenia),  which  is  secondary  achylia  gastrica.  The 
primary  achylia  gastrica  is  either  congenital  or  developed  on  the  basis 
of  a  very  early  predisposition.  It  is  associated  with  inherited  debil- 
ity of  the  nervous  system,  and  prevails  among  so-called  neuropathic 
patients. 

Primary  secretory  debility  of  the  stomach  is  an  individual  pecu- 
liarity, which  may  remain  latent  for  years,  and  without  demon- 
strable detriment  to  the  general  organism.  This  is  particularly  the 
case  when  the  motor  function  is  well  preserved,  and  the  motor, 
secretory,  and  resorptive  functions  of  the  intestine  continue  normal. 

The  mucosa,  which  is  devoid  of  secretion,  exhibits  a  diminished 
vital  resistance  to  all  external  detrimental  influences.  This  explains 
the  fact  that  anatomical  alterations  of  varying  intensity  are  rarely 
absent  in  simple  achylia  gastrica.  The  structural  changes  bear  no 
proportionate  relation  to  the  absolute  gravity  of  the  loss  of  function. 

It  is,  therefore,  probable  that  there  are  forms  of  so-called  atrophy 
of  the  gastric  mucosa  (the  primary  noncarcinomatous  anadenia) 
which  develop  preferably  on  the  basis  of  this  congenital  secretory 
weakness  of  the  stomach. 

Accordingly,  there  are  gradual  transitions,  clinically  and  ana- 
tomically, from  congenital  simple  achylia  with  but  immaterial  altera- 
tions of  the  mucosa,  to  achylia  with  chronic  granular  gastritis  even- 
tuating in  complete  atrophy  of  the  secretory  mucosa. 

The  grave  results  for  the  total  organism  (progressive  anemia, 
malnutrition,  etc.)  which  have  been  ascribed  to  the  latter  type  do  not 


854  ACHYLIA    GASTRIC  A. 

in  reality  develop  until  the  mucous  membrane  of  the  intestine  is 
extensively  involved  by  the  atrophy. 

Pathological  Histology. — The  investigations  made  by  the 
authors  quoted  in  the  literature  at  the  end  of  this  chapter  show  in 
general  a  marked  increase  in  the  interstitial  connective  tissue.  The 
surface  epithelium  contains  many  goblet  cells.  The  vestibules  to 
the  glandular  alveoli  are  very  tortuous,  and  so  dilated  that  they 
resemble  minute  cysts,  filled  with  homogeneous,  slightly  granular 
masses,  that  stain  with  acid  anilin.  The  epithelial  cells  lining  the 
vestibules  present  marked  variations  in  structure  and  staining  quali- 
ties. Those  most  prominent  are:  (i)  Ordinary,  long,  cylindrical, 
epithelial  cells.  (2)  Somewhat  shorter,  cylindrical  cells  with  dark 
protoplasm  and  dark-staining  nucleus,  the  upper  end  of  which  has 
disappeared.  (3)  Goblet  cells.  (4)  Cells  as  in  type  2,  but  with  a 
very  dark  protoplasm  (Stohr  cells).  (5)  Cells  with  a  marked  fuch- 
sinophilic  granulation.  In  some  vestibules  only  cells  answering  to 
the  description  of  type  2  are  found,  and  in  them  an  abundance  of 
mitotic  figures.  In  other  vestibules  we  find  goblet  cells  in  addition 
to  these.  There  are  very  few  vestibules  which  contain  normal  sur- 
face epithelium. 

Among  the  other  characteristics  that  were  found  in  freshly  hard- 
ened stomachs  of  achylic  patients  are:  (i)  Immigration  and  per- 
meation of  leukocytes.  (2)  The  occurrence  of  mitoses  in  the  surface 
epithelium  and  in  that  lining  the  vestibular  alveoli.  The  author's 
cases  were  especially  examined  with  regard  to  atypical  or  pathological 
mitoses,  but  the  results  were  negative.  (3)  Occurrence  of  acidophilic 
leukocytes.  (4)  Frequency  of  goblet  cells.  (5)  Occurrence  of  so- 
called  Stohr's  and  Nussbaum's  cells.  (6)  Occurrence  of  hyaline 
spheres. 

Referring  to  No.  i  of  the  above  observations,  it  should  be  stated 
that  Sachs  ("Zur  Kenntniss  d.  Magendriisen  b.  krankhaften  Zustan- 
den,"  Breslau,  1886)  has  found  an  abundance  of  lymph-cells  migrat- 
ing through  the  surface  epithelium  and  glandular  substance.  The 
pyloric  region  seems  to  be  more  invaded  than  any  other  part  of  the 
stomach.  Stintzing  considers  the  immigration  of  leukocytes  in  the 
normal  stomach  a  very  rare  occurrence.  Permeation  of  the  gastric 
mucosa  with  leukocytes  at  the  height  of  digestion  is  a  normal  occur- 
rence, and  has  been  frequently  observed  in  animals.  The  difference 
in  the  achylic  stomach,  with  regard  to  the  permeation  of  leukocytes, 
is  simply  one  of  degree.     Lubarsch  found  that  the  glandular  lumina 


HISTOLOGICAIv    CHANGERS    IN    ACHYLIA    GASTRICA.  855 

were  actually  packed  full  with  acidophilic  leukocytes ;  this  property 
has  not  been  found  in  the  leukocytes  of  the  normal  stomach.  It  is 
probable  that  the  invasion  of  the  mucosa  with  acidophilic  leukocytes 
to  such  a  degree  as  Lubarsch  describes  is  pathological. 

Concerning  No.  2,  the  presence  of  mitoses  in  the  epithelia  of  the 
normal  stomach  is  denied  by  Sachs  (Z.  c.)  and  Oppel  ("Lehrbuch  der 
vergleich.  mikroskop.  Anatomic  d.  Wirbelthiere,"  Bd.  i:  "Magen"), 
and  the  occurrence  of  karyokinetic  figures  in  the  chief  and  border 
cells  is  extremely  rare.  For  a  closer  study  of  the  character  and  sig- 
nificance of  the  mitotic  processes  I  refer  to  my  article  (Hemmeter, 
"Histological  Studies  Relating  to  the  Early  Diagnosis  of  Cancer  of 
the  Stomach,"  "Phila.  Med.  Journ.,"  Feb.,  1900).  The  hyaline 
spheres  which  Lubarsch  describes  are  composed  of  cell  granules  that 
have  become  confluent  and  enlarged,  but  are  still  contained  within 
the  body  of  the  original  cell.  These  hyaline  spheres  are  considered 
pathognomonic  for  atrophic  processes  in  the  gastric  mucosa. 

The  histological  changes  found  by  various  authors  in  achylia,  and 
which  we  have  been  enabled  to  confirm  in  cases  which  we  had  oppor- 
tunity to  examine  at  autopsies  shortly  after  death,  indicate  the  pro- 
liferation of  the  interstitial  connective  tissue,  the  occurrence  of  acido- 
philic migrating  cells ;  and,  in  addition,  the  disappearance  of  the  spe- 
cific glandular  elements  and  cell  proliferation,  emanating  from  the 
vestibules  of  the  glands;  also  transformation  of  the  gastric  mucosa 
into  intestinal  mucosa.  The  process  eventuates  in  complete  atrophy 
of  the  mucosa.  Einhorn  has  reported  a  case  of  achylia  in  which  a 
bit  of  gastric  mucosa  was  found  in  the  wash-water,  which  under  the 
microscope  appeared  normal.  We  obtained  normal  mucosa  from 
two  cases  of  achylia,  when  strips  were  cut  from  achylic  stomachs 
running  from  the  esophagus  along  the  greater  curvature  to  the  duo- 
denum ;  on  serial  sections  made  at  intervals  of  one  inch  apart,  small 
areas  of  microscopically  normal  mucosa  were  found,  particularly  near 
the  cardia,  while  most  other  portions  of  the  stomach  showed  distinct 
atrophic  changes,  with  profuse  immigration  of  leukocytes,  and  pro- 
liferation of  the  interstitial  connective  tissues.  A  small  bit  of  mucosa 
accidentally  found  in  the  wash-water  does  not  indicate  the  state  of 
the  entire  stomach.  When  such  normal  fragments  are  found  in 
achylia,  it  is  still  probable  that  other  portions  of  the  stomach  may  be 
diseased,  and  what  may  be  a  normal  condition  in  a  fragment  from 
the  fundus  or  pyloric  region,  will  be  pathological  for  the  intermediate 
zone  (Martins  and  Lubarsch,  I.  c. ;  also  Hemmeter,  /.  c).     We  no  not, 


856  ACHYLIA  GASTRIC  A. 

therefore,  consider  the  evidence  satisfactory  that  achylia  may  exist 
with  a  perfectly  normal  gastric  histology. 

In  the  great  majority  of  cases  of  achylia,  a  progressive  atrophic 
gastritis  may  be  found  to  exist.  There  may  be  periods  in  the  history 
of  achylia  when  this  condition  exists  without  any  apparent  alteration 
in  the  gastric  mucous  membrane,  and  the  fact  that  most  patients  do 
not  consult  the  physician  until  the  process  has  developed  to  a  very 
advanced  state  may  explain  the  observation  that  the  occurrence  of 
achylia  with  perfectly  normal  stomachs  is  thus  far  supported  by  very 
few  reliable  microscopic  examinations  of  gastric  tissue  fragments. 
All  achylic  patients  give  a  history  of  years  of  gastric  disturbances 
when  they  first  present  themselves  for  treatment,  the  anamnesis  thus 
making  it  probable  that  the  gastric  changes  must  have  progressed 
very  far.  In  the  case  of  the  healthy  medical  student  in  whom  we 
found  achylia  on  six  different  examinations,  we  did  not  succeed  in 
obtaining  a  piece  of  the  gastric  mucosa.  In  these  cases  frequent  ex- 
aminations for  fragments  of  mucosa  are  necessary  to  decide  the  rela- 
tion between  the  histological  alteration  and  the  clinical  history. 
These  examinations  should  be  made  at  frequent  and  regular  inter- 
vals, and  in  case  of  autopsies  on  achylic  patients  the  stomach  should 
be  previously  preserved  by  pouring  in  alcohol  or  2^enker's  fluid  within 
a  half  hour  after  death,  so  as  to  prevent  autodigestion.  What  rela- 
tion exists  between  the  atrophic  process  of  the  intestines  and  that  of 
the  stomach  is  unknown.  It  may  be  a  direct  continuation  of  the 
progressive  gastritis,  since  it  is  very  probable  that  the  same  detri- 
mental agencies  that  cause  the  disease  of  the  stomach  give  rise  to  the 
intestinal  atrophy.  One  might  assume  also  that  excessive  demands 
are  made  upon  the  digestive  power  of  the  intestines  in  the  absence  of 
the  preparatory  digestive  function  of  the  stomach.  Again,  it  is 
probable  that  bacterial  fermentations  occur  to  a  much  greater  degree 
when  the  disinfecting  power  of  the  HCl  is  lost.  In  two  autopsies  on 
subjects  who  had  shown  the  symptoms  of  achylia,  the  author  ob- 
served that  the  celiac  axis,  and  all  branches  arising  from  it,  were  of 
unusually  small  size.  The  gastric  arteries  were  smaller  than  those 
of  normal  stomachs.  The  intestinal  and  mesenteric  arteries  were 
also  smaller  in  diameter  than  normal.  The  dimensions  of  the  hepatic 
and  splenic  arteries  were  smaller.  The  arteries  of  the  heart,  spleen, 
kidney,  and  liver  appeared  normal  in  size.  On  injecting  the  arteries 
of  the  stomach  from  the  celiac  axis,  the  diminutive  caliber  of  the 


ETIOLOGY   OF    ACHYLIA    GASTRICA.  857 

arteries  was  evident  even  without  micrometric  measurements.    There 
was  in  this  case  no  atrophic  gastritis. 

Etiology. — Aside  from  the  probabihty  that  achylia  may  be  either 
congenital  or  developed  upon  a  neuropathic  basis,  not  much  is  known 
of  the  causation  of  the  progressive  atrophic  gastritis.  It  has  been 
supposed  that  bacterial  infection  is  an  etiological  factor  in  bringing 
about  this  state  of  the  mucosa.  We  may  conceive  the  bacterial  inva- 
sion to  have  occurred  in  a  similar  manner  to  that  pictured  under  the 
head  of  ulcus  carcinomatosum.  In  one  of  our  drawings  the  presence 
of  bacilli  is  represented  beneath  the  floor  of  the  ulcer,  some  of  them 
located  in  the  muscularis.  (Plate  IX  and  Fig.  39,  p.  532.)  It  is 
not  known  whether  this  bacterial  invasion  is  a  cause  or  result  of  these 
processes.     Syphilis  and  tuberculosis  may  be  predisposing  factors. 

Example  of  Clinical  History. — Mr.  L.  W.,  thirty-two  years  old,  reporter  on 
a  daily  newspaper.  Up  to  1894  he  was  physically  well  and  in  good  health, 
although  he  admits  to  have  frequently  abused  his  stomach  by  overeating  and 
overdrinking.  His  mother  is  a  highly  neurasthenic  woman,  who  imagines  she 
is  afflicted  with  all  sorts  of  ailments  ;  father,  high-strung  and  arbitrary.  His 
duties  necessitate  that  he  should  be  awake  during  the  night  and  sleep  during 
the  day.  As  a  consequence  of  this,  he  is  compelled  to  take  his  meals  at  very 
irregular  hours.  He  frequently  does  not  obtain  sufficient  sleep,  being  awak- 
ened by  noises  in  the  street  (trolley  cars,  etc.)  and  about  the  house  in  which  he 
lives.  He  usually  gets  to  bed  about  five  o'clock  in  the  morning,  and,  if  his 
nerves  are  quiet,  sleeps  until  eleven  or  twelve  ;  then,  arising,  he  takes  his  break- 
fast. His  main  meal  is  taken  between  five  and  six  o'clock  in  the  afternoon. 
At  seven  o'clock  he  must  report  for  duty  as  night  clerk  or  reporter  of  the  Asso- 
ciated Press.  The  work  he  has  to  perform  is  frequently  of  an  exciting  and 
enervating  character.  During  the  summer  of  1894,  while  it  was  very  hot,  he  had 
indulged  in  very  cold  beer  during  the  night  while  following  up  some  sporting 
occasion,  and  since  then  has  suffered  from  dyspepsia,  nausea,  eructation,  etc. 
Sometimes,  after  a  meal,  he  will  be  attacked  with  palpitation  of  the  heart  and 
a  feeling  of  giddiness,  which  has  recently  been  associated  with  sensations  of 
precordial  fear.  His  appetite  in  the  summer  of  1895  was  very  poor;  the  food 
was  described  as  weighing  down  his  stomach  like  a  lump  of  lead.  Heart  pal- 
pitation so  strong  that  he  can  not  sleep  because  of  the  noise  his  heart  makes. 
In  one  month  of  the  summer  of  1895  he  lost  eleven  pounds. 

Analysis  of  Test-meal. — The  first  test-meal  had  disappeared  from  the 
stomach  entirely  fifty-five  minutes  after  it  had  been  eaten.  The  second  test- 
meal  was  drawn  fifty  minutes  after  it  had  been  taken  ;  the  amount  was  about 
three  ounces,  and  it  consisted  of  chewed  particles  of  wheat  bread  entirely  un- 
changed. Total  acidity  =  5  ;  free  HCl  =^  negative  ;  combined  HCl,  negative  ; 
lactic  acid,  trace  ;  propeptone  and  peptone,  absent.  On  test  by  milk  digestion, 
rennin  and  rennin-zymogen,  absent;  pepsinogen,  absent;  very  slight  quantity 
of  mucus  ;  very  slight  amount  of  filtrate  gained  by  pressing  the  drawn  ingesta 
through  a  sieve.  Test  of  motor  function,  by  the  Hemmeter  method,  shows  a 
rather  increased  peristalsis. 


858  ACHYLIA  GASTRICA, 

Absorption  (Penzoldt  and  Faber's  method)  is  abnormally  delayed.  Exam- 
ination of  a  fragment  of  mucosa  shows  irregular  dilations  of  the  peptic  gland- 
ducts  ;  there  is  some  increase  of  the  interglandular  connective  tissue,  which 
is  infiltrated  with  tremendous  numbers  of  leukocytes,  which  have  also  per- 
vaded the  epithelial  cells  of  the  vestibules.  Here  and  there  the  entire  lumen 
of  the  gland-duct  is  packed  full,  and  apparently  pushed  apart  with  an  enormous 
invasion  of  lymphoid  cells.  The  characteristic,  spindle-shaped,  connective- 
tissue  cells  are  present,  but  unless  carefully  sought  for,  they  escape  detection, 
on  account  of  a  copious  round-cell  infiltration,  and  of  the  invasion  of  leuko- 
cytes, to  which  reference  has  been  made.  Many  eosinophilic  cells  present.  In 
the  epithelia,  cells  with  numerous  chromosomes  and  others  containing  more 
than  one  nucleus.  The  nuclei  in  these  cells  are  in  various  stages  of  indirect 
division,  showing  typical  mitotic  figures. 

Anatomical  diagnosis,  chronic  granular  gastritis.  This  patient  improved 
very  much  after  a  vacation  of  six  weeks  in  the  summer,  which  brought  him  the 
necessary  sleep  at  night  and  rest.  Remedies  to  restore  HCl  secretion  have  been 
tried  persistently  for  one  year  and  six  months  without  effect.  He  repeatedly 
suffered  in  the  hot  season  of  the  year  from  attacks  of  diarrhea,  which  were 
easily  controlled  by  administering  HCl  and  subnitrate  of  bismuth,  together 
with  a  proper  diet.  The  patient  has  relapses  whenever  he  indulges  in  over- 
work, with  loss  of  sleep.  Since  1895,  twenty-three  test-meal  analyses  have 
been  made,  not  one  showing  a  trace  of  HCl  or  ferments. 


Treatment. — At  my  clinic  we  are  in  the  habit  of  prescribing  dilute 
HCl  for  all  these  cases  whenever  the  acid  agrees  well.  As  consider- 
able HCl  is  needed  to  effect  any  appreciable  digestive  action  and  to 
exert  a  disinfecting  influence,  we  give  twenty  drops  of  the  official 
dilute  HCl  every  half -hour  after  meals  until  sixty  drops  have  been 
taken.  The  acid  must  be  largely  diluted  and  taken  in  a  double 
gelatin  (Aaron)  capsule  or  through  a  glass  tube.  Our  experience, 
which  is  based  upon  a  large  number  of  cases  of  this  sort,  has  convinced 
us  that  the  acid  is  not  only  well  tolerated,  but  is  almost  indispensable 
to  the  patient.  Although  it  may  be  argued  that  achylic  patients 
sometimes  get  along  without  any  treatment  whatever,  simply  because 
they  exhibit  no  symptoms,  nevertheless  when  they  do  apply  for  treat- 
ment they  generally  present  a  complexity  of  symptoms,  which  are 
much  benefited  by  carefully  selected  but  nutritious  diet,  sometimes 
rest  in  bed,  strychnin,  and  HCl.  When  the  appetite  is  absolutely 
lost,  it  may  be  restored  by  washing  out  the  stomach  with  bitter 
tonics,  such  as  gentian  and  quassia.  In  neurasthenic  patients, 
stiy^chnin  sulphate  improves  not  only  the  local  gastric  S3'mptoms, 
but  also  the  symptoms  of  the  general  neurasthenia.  A  number  of 
gastric  patients  of  this  kind  refuse  to  eat,  because  they  fear  that  dis- 
tress will  be  caused  by  the  food.     In  such  cases  it  may  become  neces- 


DIET   IN    ACHYLIA    GASTRICA.  859 

sary  to  place  the  patient  in  a  well-managed  institution  for  the  dietetic 
treatment  of  digestive  diseases.  They  must  gradually  be  convinced 
that  food  that  is  ingested  with  appetite  can  do  no  harm.  When  the 
motility  is  interfered  with  and  symptoms  of  dilation  are  manifest, 
gastric  lavage  is  indispensable.  Concerning  the  use  of  pepsin  and 
pancreatin  see  pages  345  and  346. 

Diet. — The  ach^dic  patient  is  an  individual  who  has  an  internal 
infirmity,  due  either  to  a  congenital  defect,  or  to  an  acquired  abnor- 
mality in  the  gastric  structure.  Whatever  may  be  the  condition  and 
the  cause,  we  are  dealing  with  individuals  who  are  essentially  weak 
and  debilitated.  We  have  found  it  expedient  not  to  be  too  exacting 
with  diet  orders.  In  fact,  we  make  it  a  rule  never  to  give  a  standing 
diet  order  to  an  achylic  patient  without  carefully  inquiring  as  to  the 
food  which  he  knows  from  experience  agrees  best  with  him.  The 
stomach  is  a  protective  and  selective  organ,  preparing  the  food  for 
the  intestines.  By  its  selective  property,  when  the  motility  is  in  a 
normal  condition,  it  permits  only  the  semisolid  and  liquid  masses  to 
pass  first,  while  the  more  consistent  masses  are  retained,  to  be  further 
softened  and  disintegrated.  We  have  shown,  in  the  preceding  pages, 
that  the  stomach  of  the  achylic  patient  has  lost  the  power  to  dilute 
its  contents  b}^  a  secretion  from  its  walls.  This  is  one  of  the  main 
reasons  why  we  permit  the  ingestion  of  liquids  during  meals,  and  of 
largely  diluted  HCl  after  meals.  For  the  same  reason  all  foods  should 
be  well  chewed,  or  preferably  finely  divided  during  the  process  of 
cooking,  for  the  main  object  of  all  treatment  must  be  to  preserve  the 
peristalsis,  and  to  insure  a  healthy  state  of  the  mucosa.  Therefore, 
the  food  should  generally  be  taken  in  the  form  of  gruels,  pastes,  or 
in  any  semisolid,  easily  swallowed  state.  The  meat  should  be  very 
soft,  scraped,  or  run  through  the  meat-grinder.  Fish,  sweetbread, 
calf's  brain,  and  soft-boiled  eggs  are,  as  a  rule,  of  such  soft  consistency 
that  they  need  no  further  preparation.  Our  experience  is  that  the 
more  food  is  ingested  and  well  tolerated,  the  better  for  the  patient 
in  these  cases.  We  will  give  no  outline  here  of  detailed  diet  list,  but 
refer  the  reader  to  the  diet  order  for  anacidity  and  Penzoldt  graded 
diet  order  given  in  the  chapter  on  Dietetics.  In  many  cases  physical 
and  mental  rest,  h3^gienic  surroundings,  and  a  nourishing  diet  will 
be  all  that  are  needed  for  insuring  comparative  well-being  of  the 
patients.  Where  the  motor  power  becomes  defective,  the  treatment 
will  be  that  outlined  in  the  chapter  on  Motor  Insufficiency. 

A  remedy  little  known,  but  a  very  valuable  adjuvant  in' treatment 


86o  NERVOUS   DYSPEPSIA. 

for  lack  of  dietetic  ferment,  is  the  juice  of  fresh  pineapple.  This  has 
decided  proteolytic  power,  and,  besides,  is  a  pleasant,  easily  pro- 
cured remedy.  The  ferment  is  only  active  in  the  fresh  fruit,  and  is 
destroyed  in  the  preserved  pineapple.  The  name  "Bromelin"  has 
been  given  to  the  ferment  b}^  Chittenden  ("Journ.  Physiol.,"  xv, 

1894)- 

There  is  no  treatment  that  is  universally  applicable  to  all  cases  of 
achylia.  The  ability  of  the  practitioner  in  discerning  the  special 
indications  for  each  individual  case  is  put  to  the  test  severely  in  the 
therapeutic  management  of  this  disease.  Sometimes  the  treatment 
will  be  that  of  chronic  gastritis,  sometimes  that  of  nervous  dyspepsia. 
Excessive  strictness  in  dietetic  regulation  has,  in  the  author's  opin- 
ion, occasionally  developed  gastric  "hypochondriacs."  It  is  more 
advisable  to  train  up,  or,  as  Broadbent  says,  "level  up,"  the  gastric 
digestion  to  a  higher  plane.  We  make  it  a  rule  to  show  these  gastro- 
phobic  patients  the  contents  of  their  stomach  at  a  proper  time  after 
full  meals,  to  convince  them  that  they  can  digest  thoroughly,  for,  as 
a  rule,  every  vestige  of  food  will  have  passed  out  of  the  organ  within 
one  and  one-half  hours. 

The  literature  on  achylia  gastrica  will  be  found  compiled  in  the 
article  by  Martins  and  Lubarsch,  published  by  Franz  Deuticke, 
Leipzig,  1897. 


CHAPTER  XIV. 


NERVOUS  DYSPEPSIA  (Leube).— NEURASTHENIA 
GASTRICA  (Ewald). 

The  original  definition  which  Leube  gave  of  this  affection  char- 
acterized it  as  a  neurosis  of  sensibility,  without  any  well-defined  and 
constant  objective  disturbances  of  digestion,  but  exhibiting  a  large 
variety  of  subjective  symptoms  connected  with  the  digestive  act  and 
occurring  independently  of  any  demonstrable  changes  in  the  stomach. 

In  his  first  paper  Leube  ("Ueber  nervose  Dyspepsie,"  "Deutsch. 
Arch.  f.  klin.  Med.,"  Bd.  xxiii,  1879)  emphasized  that  the  gastric 
digestion  may  be  perfectly  normal  so  far  as  the  chemistry  and  motil- 
ity are  concerned,  and  that  he  has  used  the  term  "dyspepsia,"  or 


DEFINITION    OF    NERVOUS    DYSPEPSIA.  86 1 

difficult  digestion,  because  this  act  is  accompanied  by  manifold  com- 
plaints that  are  traceable  to  an  abnormal  excitability  of  the  sensory 
gastric  nerves.  Since  then  Leube  has  expanded  the  conception  of 
nerv^ous  dvspepsia  to  the  effect  that  it  includes  anomalies  of  secretion 
and  motility. 

R.  Geigel  and  Abend  (pupils  of  Leube)  later  on  demonstrated  that 
the  secretion  of  HCl  may  be  extremely  variable  in  nervous  dyspepsia, 
and  that  we  may  have  a  normal  acidity,  or  euchlorhydria,  subacidity, 
anacidity  or  achylia,  or  hyperacidity.  Accordingly,  the  important 
svmptoms  of  the  trouble — viz.,  the  annoying  gastric  distress — can 
not  be  traced  to  fermentations  of  the  gastric  contents  with  sub-  or 
inaciditv,  nor  to  the  products  of  this  decomposition,  nor  to  irritation 
of  the  gastric  nerves  in  superacidity.  It  is  natural  that  the  defini- 
tions and  conceptions  of  various  authors  concerning  a  disease  that  is 
so  vague  and  indefinite  in  its  clinical  history  and  pathology  should 
differ  greatly.  Leube  distinguishes  more  recently  between  two  kinds 
of  nervous  dyspepsia:  (a)  Nervous  dyspeptic  symptoms  in  which 
the  nervous  channels  are  sympathetically  involved  by  anatomical 
changes  in  the  stomach,  and  altered  chemistry  of  digestion  caused 
bv  these  changes,  (b)  Nervous  dyspepsia  with  an  apparently  normal 
anatomical  state  of  the  organ.  Boas  distinguishes  a  third  form  of 
nervous  dyspepsia,  which  originates  reflexly  from  other  organs :  for 
instance,  the  kidneys,  uterus,  ovaries,  male  genito-urinary  apparatus, 
and  intestine.  Constitutional  diseases,  such  as  tuberculosis,  syphilis, 
diabetes  mellitus,  anemia,  uric  acid  diathesis,  may  form  the  basis  of 
this  complexity  of  symptoms.  The  disease  may  occur  in  an  idio- 
pathic form,  independently  of  any  demonstrable  gastric  changes,  or 
in  a  secondary  form  consequent  upon  neurasthenia,  hysteria,  and  the 
other  pathological  states  referred  to.  Whatever  the  underlying  basis 
or  etiology  of  the  disease,  the  ultimate  symptoms  can  be  ascribed  to 
a  functional  sensory  neurosis  and  overexcitability  of  the  gastric 
nerves,  which  may  become  so  acute  that  they  react  in  a  pathological 
manner  upon  the  influence  of  normal  digestive  stimulation. 

Pathology. — Jiirgens  has  discovered  total  degeneration  of  the 
plexus  of  Meissner  and  Auerbach  in  forty-one  cases  of  nervous  dys- 
pepsia. In  one  of  the  cases  in  which  the  sensor)^  disturbances  were 
predominant,  and  the  intestinal  functions  involved  also,  this  author 
found  a -distinct  degeneration  of  the  muscularis  of  the  stomach  and 
intestine.  Further  exact  pathological  and  histological  investigation 
will  very  probably  restrict  the  number  of  cases  at  present  classed 


862  NERVOUS   DYSPEPSIA. 

under  nervous  dyspepsia.  The  conceptions  of  various  authors  con- 
cerning the  nature  of  nervous  dyspepsia  vary  considerably.  Leube, 
as  is  well  known,  states  that  nervous  dyspepsia  is  of  central  origin, 
while  Stiller  applies  the  name  to  all  digestive  disturbances  that  are 
transmitted  to  the  stomach  through  the  central  or  the  sympathetic 
nervous  system.  Stiller  attributes  greater  importance  than  Leube 
to  disturbances  of  the  secretory  function,  which  he  could  demonstrate 
in  a  majority  of  his  cases.  We  interpret  the  disease  as  a  mixed 
neurosis,  in  which  the  motor  secretory  and  sensory  nerve  apparatus 
are  affected  contemporaneously  or  alternately;  an  anatomical  sub- 
stratum is  present  in  one-half  of  the  cases,  but  it  is  not  of  a  con- 
stant type. 

Etiology. — Neurasthenia  gastrica  has  been  observed  after  intense 
emotional  excitement,  exhaustive  mental  work,  alcoholic  and  sexual 
excesses,  after  abuse  of  tobacco,  and  associated  with  pulmonary 
phthisis,  nephritis,  and  malaria.  The  sensibility  of  the  normal  gas- 
tric mucosa  is  very  slight,  and  the  digestive  irritation  causes  no  dis- 
tinct sensation  in  the  normal  individual,  but  when  a  healthy  person 
transgresses  the  customary  amount  of  food,  unpleasant  sensations 
of  pressure,  distention,  fullness,  eructation,  and  nausea  will  ensue, 
indicating  that  the  organ  has  been  overloaded.  These  sensations 
cease  when  a  part  of  the  chyme  has  passed  out  into  the  intestine. 

Narcotic  substances,  such  as  very  strong  coffee,  tea,  or  tobacco, 
may  relieve  or  remove  these  symptoms,  showing  that  they  are  of  a 
purely  nervous  character.  If  the  excitability  of  the  sensory  nerves 
is  for  any  reason  increased,  then  the  normal  digestive  irritation  brings 
about  such  gastric  difficulty.  It  is  characteristic  of  nervous  dyspep- 
sia that  gastric  distress  is  perceived  only  after  meals,  and  is  absent 
when  the  stomach  is  empty.  With  an  intensely  excitable  nervous 
apparatus  in  the  stomach,  such  symptoms  as  we  have  described 
may,  in  exceptional  cases,  come  on  even  when  the  organ  is  empty. 
The  nervous  dyspepsia  associated  with  malaria  should  induce  the 
physician  to  examine  the  blood  of  the  patient  for  the  malarial  para- 
site. The  symptoms  in  these  cases  generally  abate  under  the  influ- 
ence of  quinin. 

As  a  secondary  neurosis,  neurasthenia  gastrica  is  generally  the 
result  of  general  neurasthenia  or  hysteria.  Grave  anatomical  altera- 
tions of  the  brain  and  spinal  cord,  which  frequently  bring  on  other 
gastric  neuroses,  are,  so  far  as  we  know,  not  reported  to  have  any 
causal  relation  to  nervous  dyspepsia. 


SYMPTOMATOLOGY   OI^   NEURASTHENIA   GASTRICA.  863 

Refiexly,  the  disease  may  result  from  irritation  arising  from  the 
genito-urinary  organs  in  both  sexes,  from  menstrual  and  puerperal 
disturbances.  The  dyspepsia  during  the  puerperal  periods  has  been 
attributed  to  traction  or  compression  of  the  sympathetic.  In  a  por- 
tion of  the  cases  it  is  impossible  to  attribute  any  cause.  It  is  a  dis- 
ease which  prevails  among  the  male  sex. 

Symptomatology. — The  clinical  picture  of  neurasthenia  gastrica 
is  extremely  variable.  It  is,  therefore,  impossible  to  give  a  well- 
defined,  typical  representation  of  the  disease  that  can  be  applicable 
to  the  majority  of  the  cases.  We  will,  therefore,  simply  designate 
the  most  important  and  frequent  symptoms.  It  is  characteristic  of 
nervous  dyspepsia  that  the  gastric  distress  is  directly  dependent  upon 
the  ingestion  of  food — that  it  occurs  as  a  rule  only  after  meals,  and 
not  on  an  empty  stomach. 

Furthermore,  it  is  characteristic  that  the  quality  and  the  quantity 
of  the  food  and  dietetic  errors  exert  no  influence  upon  dyspepsia. 
At  times  the  most  indigestible  food  causes  no  difficulty  whatever, 
and  at  other  times  the  most  digestible  food  brings  on  distress.  The 
sensations  of  the  patient  are  very  much  under  the  influence  of  the 
emotional  state.  The  dyspeptic  symptoms  are:  Unpleasant  sensa- 
tions, pressure,  fullness,  distention  of  the  stomach,  occurring  shortly 
after  meals.  After  the  patients  have  slept  well,  they  are  in  a  cheer- 
ful state  of  mind  in  the  morning,  but  immediately  after  breakfast 
they  are  tormented  by  manifold  sensations  in  the  stomach.  The 
suffering  is  most  severe  when  the  neurasthenia  gastrica  is  accom- 
panied by  hyperacidity.  In  this  case  it  increases  during  the  second 
period  of  digestion,  as  the  acidity  becomes  greater.  Such  types  are 
relieved  by  the  administration  of  alkalies,  which,  however,  are  useless 
with  achylia.  The  epigastric  region  is  not  very  sensitive,  nor  are 
there  any  characteristic  pain-points,  so  far  as  we  could  determine. 

Leven  ("Estomac  et  Carvau,"  Paris,  1884)  attributes  great  im- 
portance to  the  appearance  of  these  so-called  painful  spots,  which 
are  supposed  to  be  due  to  an  irritation  of  the  solar  plexus.  Burk- 
hart  ("Pathol,  der  Neurasthenia  Gastrica,"  Bonn,  1882),  Fleischer, 
Bwald,  Bouveret,  and  Richter  do  not  attribute  much  importance  to 
this  symptom.  In  some  cases  very  peculiar  sensations  are  described 
by  these  patients.  Some  have  a  crawling  feeling  in  the  stomach,  as 
if  some  live  animal  were  moving  about  in  it.  Some  have  a  sensation 
of  tickling,  others  describe  it  as  a  beating,  burning,  or  sticking  sensa- 
tion.    A  most  unusual  sensation  is  that  described  as  a  restless,  wavy, 


864  NERVOUS   DYSPEPSIA. 

or  undulating  motion.  Persistent  eructation  is  a  very  frequent  and 
annoving  symptom.  The  eructations  occur  in  an  explosive  manner, 
and  without  any  regard  for  the  surroundings.  If  there  is  hyper- 
acidity, these  eructations  are  accompanied  b}^  severe  pyrosis.  Emesis 
is  rare,  but  when  it  does  occur,  the  character  and  consistency  of  the 
vomit  depend  upon  the  composition  of  the  gastric  juice.  W%h 
normal  acidit}"  or  hyperacidity  it  has  a  ven,'  sour  taste  and  is  void 
of  proteid  food  when  the  acid  is  present  in  excess.  With  subacidity 
or  inacidity  it  contains  much  undigested  meat  and  eggs  and  but  little 
carbohydrate  food.  Although  inacidity  may  be  present,  the  gastric 
contents  do  not  decompose,  because  there  is  no  stagnation.  The 
appetite  is  variable.  There  may  be  a  normal  appetite,  bulimia,  or 
anorexia.  As  a  rule,  thirst  is  increased.  The  behavior  of  the  sensors'- 
gastric  nerves  is  capricious.  When  the  patient  is  in  a  cheerful 
pleasant  humor,  or  occupied  with  a  congenial,  interesting  piece  of 
work,  he  will  digest  articles  of  diet  which  will  cause  vers^  great  dis- 
tress when  he  is  emotionally  depressed  or  otherwise  indisposed.  Ex- 
cessive mental  or  bodily  work,  cares  and  worries  concerning  the 
vocation,  disappointments  in  business  enterprises,  grief,  etc.,  all 
cause  a  condition  of  excitability  in  which  digestion  is  much  impaired. 

Secretory  Function. — In  neurasthenia  gastrica  there  may  be  a 
normal  secretion,  hyperacidity,  or  inacidity.  When  inacidity  exists, 
the  ferments  can  still  be  demonstrated  in  the  gastric  contents.  This 
important  fact  will  ser\^e  to  distinguish  this  type  of  nervous  dys- 
pepsia from  typical  achylia  gastrica. 

Motor  Function. — The  peristalsis  of  the  stomach  is  in  most  cases 
undisturbed  in  neurasthenia  gastrica,  but  there  are  cases  in  which 
temporary  motor  insufficiency  occurs. 

Intestinal  Disturbances. — The  most  constant  symptom  is  obstinate 
constipation.  Very  frequently  there  are  rumbling  noises  in  the 
intestines  and  extensive  flatulence. 

Nervous  Symptoms. — These  consist  of  pain  and  pressure  in  the 
head,  giddiness,  tinnitus  aurium,  flashes  before  the  eyes,  rapid  pulse, 
exhaustion,  cool  extremities,  attacks  of  fainting,  palpitations  of  the 
heart,  dyspnea.  It  is  very  probable  that  all  these  symptoms  are 
connected  with  the  deranged  intestinal  digestion,  and  that  they  are 
due  to  the  absorption  of  toxic  products  formed  during  the  putrefac- 
tion of  food  in  the  intestines.  C.  A.  Herter  and  E.  E.  Smith  ("N. 
Y.  Med.  Jour.,"  June  22  and  29,  July  6,  13,  and  20,  1895)  have  pub- 
lished clinical  histories  and  detailed  analyses  showing  the  relations 


DIAGNOSIS    OF   NEURASTHENIA    GASTRICA.  865 

of  psychical  disturbances,  melancholia,  etc.,  to  the  toxicity  of  the 
urine.  It  is  conceivable  that  the  production  of  these  symptoms, 
particularly  frontal  headache,  beating  in  the  head,  congestions, 
pulsations  of  the  large  arteries,  globus  hystericus,  melancholia,  and 
insomnia,  is  in  some  wa)'  related  to  excessive  intestinal  putrefaction. 
When  the  nervous  dyspepsia  is  comparatively  recent,  the  symp- 
toms are  limited  to  the  gastro-intestinal  tract,  but  when  the  disease 
is  of  long  standing,  the  ner^'ous  symptoms  may  submerge  the  diges- 
tive, and  it  may  be  difficult  to  decide  whether  the  latter  or  the  former 
constitute  the  primary  derangement. 

Diagnosis. — As  a  general  rule,  it  will  be  found  that  the  nervous 
dyspepsia  is  coimected  with  some  organic  disease  of  one  of  the  diges- 
tive organs.  We  refer  to  the  various  anomalies  of  position  of  the 
intra-abdominal  organs  that  are  described  in  the  chapter  on  Gas- 
troptosis  and  Bnteroptosis.  Frequently,  dislocated  kidneys,  small 
tumors,  hernise  of  the  median  linea  alba,  morbid  changes  in  the  male 
or  female  sexual  organs,  and  organic  diseases  of  the  stomach  and 
intestines,  will  be  found  to  exist.  There  will  be  no  connection  be- 
tween the  quaHty  and  quantity  of  the  food  and  the  digestive  difficul- 
ties, but  sleep,  emotional  state,  and  psychical  condition  will  be  in- 
fluential factors.  The  complaints  of  the  patient  are  frequentlv 
described  in  exaggerated  language.  One  of  our  patients,  who  is  the 
owner  of  a  brickyard,  describes  his  feelings  as  ' '  similar  to  the  rolling 
of  a  ton  of  bricks  in  his  belly  " ;  another  compares  his  sensation  to 
being  "stabbed  with  a  red-hot  knife";  still  another  describes  her 
abdomen  as  being  ' '  distended  to  bursting,  like  a  balloon, ' '  or,  at  other 
times,  as  feeling  compressed  as  though  it  were  in  a  vise.  At  other 
times  these  same  patients,  without  recognizable  reason,  will  make  no 
complaints  at  all,  will  be  ver\^  happy  and  cheerful,  and  digest  well. 
These  variations  in  the  functional  powers  of  digestion  are  ven,-  char- 
acteristic of  nervous  dyspepsia.  Leube  has  called  our  attention  to 
the  emptiness  of  the  stomach  seven  hours  after  a  rather  heavy  test- 
meal. 

Prognosis. — Inasmuch  as  the  course  of  the  disease  is  a  chronic 
one,  it  may,  in  severe  cases,  by  continued  and  progressive  loss  of 
strength  and  emaciation,  prove  fatal.  In  those  cases  in  which  a  cure 
has  been  effected  relapses  may  occur,  so  that  the  prognosis  should  be 
guarded'.  Sometimes,  when  the  fundamental  disease  is  remediable, 
— for  instance,  in  genito-urinary  disturbances,  malaria,  etc., — or 
when  the  cause,  such  as  sexual  excesses,  abuse  of  alcohol  and  tobacco, 


866  NERVOUS   DYSPEPSIA. 

bodily  and  mental  overexertion,  can  be  removed,  the  resulting  ner- 
vous dyspepsia  may  be  permanently  cured. 

Heterochylia  (from  irsooc,  meaning  "other  "  or  "different,"  and 
/y/or,  meaning  "juice"  or  "secretion"). — This  term  is  suggested 
by  the  author  to  denote  a  rapidly  alternating  state  of  secretion,  oc- 
curring chiefly  in  nervous  dyspepsia.  In  making  a  large  number  of 
analyses  in  these  cases.  Dr.  K.  L.  Whitney  and  the  author  have  ob- 
served within  one  week  that  euchlorhydria,  hyperchlorhydria,  and 
inacidity  will  be  found  after  the  same  test-meals.  In  the  discussion 
of  a  paper  read  before  the  American  Medical  Association,  in  Phila- 
delphia, June  4,  1897,  a  colleague,  Dr.  B.,  of  Brooklyn,  stated  that  in 
his  own  case  he  had  observed  hyperacidity  and  inacidity  on  the  same 
day,  after  he  had  taken  the  identical  meals  and  drawn  a  sample 
within  one  hour  after  they  had  been  ingested.  Dr.  E.,  who  is  an 
able  chemist,  made  quantitative  analyses  of  his  gastric  juice  on  many 
occasions,  and,  so  far  as  he  can  tell,  these  variations  in  the  secretion 
are  independent  of  his  emotional  state.  In  a  number  of  the  cases 
examined  by  Dr.  Whitney  and  the  author  they  found  hyperacidity 
with  rapid  digestion  of  proteids,  and  defective  carbohydrate  diges- 
tion, with  symptoms  of  pyrosis  and  eructation  that  were  relieved 
by  alkalies.  Two  days  afterward  the  author  examined  the  same 
cases,  to  find  that  two  of  them  showed  no  reaction  with  Congo  paper, 
no  free  nor  combined  HCl,  and  a  pronounced  HCl  deficit.  There 
was  no  pyrosis  nor  eructation,  but  the  patients  complained  of  a  sense 
of  fullness  and  weight  in  the  stomach,  together  with  anorexia,  which 
symptoms  were  relieved  by  two  doses  of  dilute  HCl  (thirty  drops 
per  dose).  At  the  end  of  the  same  week  we  had  occasion  to  examine 
the  same  cases  again,  and  found  the  acidity  normal.  For  want  of 
a  better  expression  we  have  designated  these  rapidly  alternating 
states  of  secretion  by  the  name  heterochylia.  When  the  acid  is  in 
excess,  the  proteids  are  absent  from  the  test-meals,  and  rice  and 
bread  almost  undigested.  When  the  acid  is  absent,  one  may  fre- 
quently find  a  defective  proteid  digestion,  but  a  rapid  carbohydrate 
digestion.  We  have  no  explanations  to  offer  for  these  cases  beyond 
those  which  are  purely  hypothetical,  but  it  is  conceivable  that  a  closer 
histological  study  of  the  finer  ramifications  of  the  gastric  nerves, 
such  as  has  been  carried  out  with  such  admirable  regard  for  detail  by 
Henry  J.  Berkley  in  other  organs  of  the  body,  may  throw  some  light 
upon  this  puzzling  phenomenon.  For  instance,  we  may  sooner  or 
later  be  instructed  that  the  oxvntic  or  border  cehs  receive  a  different 


DIFFERENTIAL    DIAGNOSIS    AND   TREATMENT.  867 

nervous  supply  from  the  chief  or  central  cells,  or  that  both  chief  and 
border  cells  are  supplied  by  nerves  of  widely  differing  character,  one 
set  exciting  the  function,  the  other  inhibiting  it, — i.  e.,  anabolic  and 
catabolic  secretory  fibers, — but  all  this  is  premature  and  problematic. 
Dr.  Frank  H.  Murdoch,  of  Pittsburg,  in  a  report  to  the  American 
Gastro-enterological  Association  (Washington,  May,  1898),  gave  a 
large  number  of  analyses  on  cases  of  this  type,  showing  a  secretion 
varving  from  achylia  to  hyperacidity. 

Differential  Diagnosis. — Ner\^ous  dyspepsia  with  inacidity  may 
be  confounded  with  chronic  gastritis  or  carcinoma,  and  ner\^ous  d^'S- 
pepsia  with  hvperacidity  may  be  confounded  with  ulcer,  while  still 
other  forms  may  bear  a  striking  resemblance  to  atony  or  myasthenia. 
For  the  separation  of  chronic  gastritis  from  ner\'ous  dyspepsia,  the 
following  facts  are  of  importance :  Chronic  gastritis  is  accompanied 
more  frequently  by  vomiting ;  the  stomach  contains  large  quantities 
of  mucus  and  a  few  blood  streaks ;  we  may  have  also  stagnation  of  the 
contents.  The  course  of  chronic  gastritis  is  more  uniform  and  typi- 
cal, and  the  dyspeptic  symptoms  are  directly  influenced  by  the  qual- 
itv  and  quantity  of  the  ingesta.  In  carcinoma  the  distress  is  present 
at  all  times,  even  on  an  empty  stomach,  vomiting  is  frequent,  and 
the  ferments  are  absent  when  the  HCl  secretion  is  lost.  In  nervous 
dyspepsia  the  ferments  are  still  present,  though  HCl  may  be  absent. 
When  symptoms  of  stenosis  have  occurred,  there  can  be  no  difficulty 
about  the  diagnosis.  The  differentiation  of  ner^^ous  dyspepsia  from 
ulcer  becomes  difficult  only  in  those  cases  in  which  there  has  been  no 
hematemesis.  The  constant  dependence  of  gastric  pain  upon  the 
food,  the  sharply  circumscribed  pain-points  in  the  epigastric  region 
and  in  the  back,  are  unmistakable  criteria.  We  have  spoken  more 
fully  of  the  differential  diagnosis  in  the  sections  on  the  various  gastric 
diseases  with  which  nervous  dyspepsia  may  be  confounded.  It  must 
not  be  overlooked,  however,  that  nervous  dyspepsia  may  be  asso- 
ciated with  some  form  of  organic  gastric  disease. 

Treatment. — The  fundamental  causes  of  disease  should  be  hunted 
up,  and,  if  possible,  removed.  The  prospects  of  doing  this  are  favor- 
able if  the  cause  can  be  found  in  the  existence  of  intestinal  parasites, 
floating  kidney,  malaria,  and  certain  remediable  diseases  of  the 
genitourinary  organs.  In  those  forms  of  nervous  dyspepsia  which 
depend  .upon  an  undue  excitation  of  the  nervous  system,  due  to 
sexual  excesses,  abuse  of  alcohol  and  nicotin,  or  excessive  mental  and 
bodily  exertion,  improvement  can  not  be  hoped  for  unless  these 
57 


868  NERVOUS   DYSPEPSIA. 

states  are  remedied.  Patients  must  be  impressed  with  the  fact  that 
drugs  and  other  treatment  will  not  improve  them  if  they  persist  in 
their  bad  habits.  Particularly  American  business  men,  who,  with 
admirable  energy,  but  with  little  regard  for  their  own  health,  persist 
in  executing  work  which  is  too  severe  for  their  mental  and  physical 
constitution,  must  be  taught  that  the  prime  factor  in  successful  treat- 
ment is  REST.  This  class  of  cases  will,  in  the  long  run,  prove  to  be 
ver}'-  grateful  patients  if  this  truth  is  emphasized,  and  false  ex- 
pectations concerning  the  efficacy  of  drugs  and  washing  out  the 
stomach,  etc.,  corrected  at  the  beginning  of  the  treatment.  Better 
results  can  be  obtained  in  all  of  these  cases  by  a  change  of  environ- 
ment, with  absolute  psychical  and  physical  quiet,  removal  from  the 
cares  and  worries  of  business  and  household,  than  by  the  most  de- 
tailed and  complicated  treatment. 

In  connection  with  this  we  must  emphasize  the  value  of  rational 
psychical  treatment  of  nervous  dyspepsia.  The  physician  must,  in 
a  dignified  manner,  attempt  to  merit  the  absolute  confidence  of  his 
patient.  For  this  purpose  we  consider  it  important  that  he  should 
show  a  warm,  sincere  interest  in  the  suffering  of  his  patients,  even  if, 
after  a  repeated  and  thorough  examination,  he  should  become  con- 
vinced that  the  patient's  complaints  are  unreal  and  exaggerated. 
It  is  a  great  comfort  to  these  neurasthenics  to  listen  patiently  and 
sympathetically  to  their  complaints,  and  not  to  ridicule  or  criticize 
them.  The  sufferings  of  the  patient,  psychically  considered,  are 
equally  intense,  whether  they  be  real  or  imaginative. 

Gymnastics. — The  author  has  frequently  observed  marked  improve- 
ment after  a  course  of  mild  gymnastic  training  under  an  experienced 
training-master.  The  bicycle,  moderately  used,  is  a  better  means 
of  promoting  appetite  and  regular  evacuations  than  drugs.  In  a  sim- 
ilar way  horseback  riding,  rowing,  fencing,  etc.,  are  to  be  recom- 
mended. 

Climatic  Treattnent. — A  sojourn  in  the  mountains  or  at  the  sea- 
shore is  a  great  help,  inasmuch  as  it  not  only  removes  the  patient 
from  surroundings  which  maintain  his  disease,  but  at  the  same  time 
insures  rest,  quiet,  and,  above  all  things,  invigorating  fresh  air.  In 
seeking  a  resort,  fashionable  places  and  those  thronged  with  society 
should  be  avoided.  The  greater  part  of  the  day  should  be  spent  in 
the  open  air — if  possible,  in  taking  extensive  walks.  This  will  favor 
good  sleep  during  the  night.  If  there  is  persistent  hyperacidity 
with  constipation,  the  patient  will  be  benefited  by  a  sojourn  at  Bed- 
ford Springs,  Pa. 


TREATMENT    OE    NEURASTHENIA    GASTRICA.  869 

Massage. — There  is  no  doubt  that  massage  improves  the  nutrition 
of  the  muscles  and  nerves,  and  favors  a  vigorous  circulation,  metabo- 
lism, and  regular  evacuation.  Massage  should  not  be  permitted  to  be 
executed  by  the  inexperienced.  Nine-tenths  of  the  persons  claiming 
to  be  masseurs  at  the  present  time  are  charlatans.  To  be  effective, 
the  massage  must  be  studied  by  the  physician  who  has  the  case  in 
hand,  and  though  he  may  not  execute  it  himself,  he  should,  at  least, 
supervise  it. 

Hydrotherapy. — Cold  sponge  baths,  taken  in  the  morning  imme- 
diately after  arising,  have  a  bracing  effect.  A  good  method  is  to 
wrap  the  entire  body  of  the  patient  in  a  sheet  dipped  in  cold  water, 
and  while  the  patient  himself  kneads  and  beats  the  parts  of  his  body 
that  are  accessible  to  him  in  front,  another  person  must  perform 
the  massage  of  his  back ;  after  this  the  patient  is  thoroughly  rubbed 
with  a  coarse  Turkish  towel.  These  cold  rubs  should  not  last  longer 
than  three  minutes,  after  which  the  patient  must  dress  and  take  a 
walk  of  about  one  mile.  The  favorable  effects  of  hydrotherapeutic 
methods  do  not  become  manifest  until  they  have  been  applied  for 
two  or  three  weeks.  They  are  then  followed  by  improvement  in 
the  appetite  and  sleep.  When  the  insomnia  is  persistent,  we  are  very 
fond  of  prescribing  a  warm  salt  bath,  at  the  temperature  of  the  body, 
containing  four  per  cent,  of  sodium  chlorid  and  two  per  cent,  of 
sodium  carbonate.  The  patient  is  placed  in  this  bath  about  half  an 
hour  before  bedtime,  and  remains  in  it  for  about  tw^enty  minutes. 
In  highly  neuropathic  patients  the  bath  before  bedtime  has  in  my 
experience  aggravated  the  insomnia — it  should  then  be  given  about 
4  p.  M. 

Irrigations  and  Douches  of  the  Gastric  Mucosa. — These  are  used  to 
reduce  the  hyperesthesia  of  the  gastric  nerves,  and  for  this  purpose 
carbonated  waters  are  preferable  to  still  waters.  The  gastric  tube 
should  be  used  which  contains  numerous  small  lateral  openings 
instead  of  a  few  large  terminal  openings.  If  carbonated  water  can 
not  be  conveniently  obtained,  it  can  be  prepared  by  adding  citric 
acid  or  lemon  juice  to  a  one  per  cent,  solution  of  sodium  bicarbonate. 
The  amount  poured  into  the  stomach  should  not  exceed  twenty 
ounces  at  a  time. 

Electricity. — Galvanization  of  the  abdomen  and  the  spinal  region 
and  general  faradization  are  applicable  in  these  cases.  The  faradic 
current  should  be  applied  to  every  muscle  in  the  body,  with  large, 
broad,  felt  electrodes.     A  good  method  consists  in  placing  the  feet 


870  NERVOUS   DYSPEPSIA. 

of  the  patient  upon  a  large  plate  electrode  (cathode),  while  the  other 
pole  is  placed  on  the  various  muscle  groups  of  the  body.  It  is  well 
to  allow  the  large  electrode  to  remain  on  the  epigastric  region  for 
about  five  minutes,  while  the  remaining  one  is  passed  up  and  down 
over  the  spinal  column.  The  intensity  of  the  current  and  the  dura- 
tion and  localization  of  the  treatment  must  be  varied  according  to  the 
individuality  of  the  case.  According  to  Erb,  Beard,  and  Rockwell, 
this  treatment  improves  the  appetite  and  sleep,  reduces  the  psychical 
irritability,  and  creates  a  more  favorable  disposition  to  bodily  exer- 
cise. Personally,  we  may,  without  defining  the  exact  benefits  de- 
rived from  electric  treatment,  pronounce  it  to  be  an  indispensable 
adjunct  to  the  treatment  of  neurasthenia  gastrica.  Perhaps  it  in- 
fluences the  nutrition  of  the  nervous  centers,  or  perhaps  it  is  nothing 
but  systematic  massage.  At  all  events,  it  effects  an  improvement 
in  the  sufferings  of  this  class  of  patients. 

The  Diet. — In  this  disease,  more  than  in  any  other,  the  physician 
must  see  that  the  articles  of  food  possess  considerable  variety  and 
are  well  cooked  and  appetizing.  The  behavior  of  the  digestive 
functions  are  so  grotesque  that  it  is  impossible  and  useless  to  suggest 
stereotyped  diet  lists.  Experience  is  the  best  guide,  and  the  common 
phrase,  "the  proof  of  the  pudding  is  the  eating  of  it,"  is  certainly 
applicable  in  these  cases.  It  is  very  beneficial  to  the  patient  if  he 
can  take  and  well  digest  large  quantities  of  milk ;  aside  from  its  high 
nutritive  value,  milk  acts  upon  the  gastric  mucosa  like  a  soothing 
liquid  ointment,  and  is  a  dietetic  intestinal  antiseptic.  Sometimes 
when  the  patient  is  prejudiced  against  it,  it  is  possible  to  mix  it  with 
the  food  surreptitiously,  and  our  diet  lists  and  "dietetic  kitchen" 
give  many  formulas  for  this  purpose.  In  the  selection  of  the  remain- 
ing foods,  the  taste,  likes,  and  dislikes  of  the  patient  should  be  con- 
sulted so  far  as  is  consistent  with  rational  dietetics.  Articles  of 
luxury,  such  as  good  fruit — grapes,  pears,  figs,  dates,  and,  if  anacid- 
ity  exists,  fresh  pineapples — should  not  be  forbidden.  If  constipa- 
tion is  obstinate,  the  diet  should  contain  a  large  amount  of  these 
foods,  and  particularly  apples.  Concerning  the  use  of  alcoholic  bev- 
erages, no  definite  rule  can  be  given.  On  the  whole,  we  believe  that 
wines  and  beer  should  be  avoided,  unless  they  are  needed  for  stimu- 
lation and  to  improve  the  appetite.  Earge  colon  enemata  with  pure 
olive  oil  (300  c.c.  at  a  time)  are  sometimes  curative  in  the  nervous 
constipation,  particularly  the  membranous  colitis  present  in  these 
patients.     Perhaps  the  most  effective  treatment,  on  the  whole,  is  that 


MEDICINAL   TREATMENT.  87 1 

designated  as  the  Weir  Mitchell  rest-cure,  a  combination  of  hydro- 
therapeutic,  electrical,  and  dietetic  treatment,  with  gymnastics,  rest, 
massage,  and  as  much  sleep  as  possible.  When  the  state  of  the  nutri- 
tion has  been  much  reduced,  the  so-called  "Mastkur,"  a  system  of 
fattening  by  highly  nutritious  diet  and  passive  exercise,  is,  in  our 
experience,  very  effective  in  bringing  about  a  reduction  of  the  symp- 
toms and  improvement  in  the  digestive  functions.  This  "Mastkur  " 
is  not  applicable  to  all  classes  of  patients;  those  of  an  irritable  and 
restless  temperament  and  those  who  have  organic  gastric  diseases  are 
not  improved  by  it. 

Drugs. — Those  that  have  been  employed  in  neurasthenia  gastrica 
are  the  tonics,  sedatives,  and  hypnotics.  In  anacidity  the  basic 
orexin,  five  grains  three  times  a  day,  has  been  very  much  lauded  by 
Penzoldt.  The  fluid  extract  of  condurango,  one  teaspoonful  three 
times  a  day,  and  the  bitter  tonics,  calumbo,  gentian,  quassia,  in 
doses  of  one  dram  three  times  a  day,  are  sometimes  of  value,  though 
personally  we  have  seen  no  marked  results  follow  their  administra- 
tion. The  remedy  we  have  most  faith  in  is  the  sulphate  of  strychnin, 
-^  of  a  grain  three  times  a  day  continued  for  one  month,  at  least. 
When  malaria  is  associated  with  the  nervous  dyspepsia,  quinin  is  the 
remedy  "par  excellence."  Boas  and  Einhorn  speak  very  favorably 
of  the  use  of  bromids;  both  of  them  employ  mixtures  of  the  am- 
monium and  sodium  bromids.  While  the  remedies  may  have  a 
temporary  value  and  are  indispensable  for  producing  sleep  and  dimin- 
ishing the  excessive  irritability  of  the  nervous  system,  they  must  not 
be  used  continuously.  W^e  have  assured  ourselves,  by  quantitative 
analyses  of  the  toxic  products  of  the  urine,  similar  to  the  studies  of 
Herter  and  Smith  {I.  c),  that  the  toxicity  of  the  urine  is  increased  in 
nervous  dyspepsia  as  soon  as  the  total  quantity  of  bromids  admin- 
istered exceeds  six  grams  in  twenty-four  hours.  Maximo witsch 
recommends  the  following  in  neurasthenia  gastrica  existing  on  a  basis 
of  anemia: 

U .     Ferri  bromati, 

Chinin  bihydrobromic, aa     4.0  3;j. 

Ext.  et  pulv.  rad.  rhei,  q.  s.  u.  f.  pil.  No.  cxx. 
SiG. — Two  pills  three  times  daily. 

The  use  of  mineral  spring  waters  is  of  doubtful  efficacy.  When 
an  improvement  is  noticed  at  the  mineral  springs,  it  is  probably 
due  to  the  hygienic  surroundings,  the  removal  from  care  and  worry 


872  NERVOUS   DYSPEPSIA. 

and  responsibility,  and  the  discontinuance  of  the  detrimental  habits 
encouraged  at  the  home  of  the  patient.  For  further  consideration 
of  the  effect  of  mineral  waters  we  refer  to  the  chapter  on  this  subject. 
If  the  insomnia  is  persistent,  chloral  may  be  unavoidable.  It  should, 
in  these  cases,  be  given  by  rectal  enema  and  not  by  the  stomach. 
Fifteen  grains  in  two  ounces  of  starch  water  are  usually  sufficient  to 
secure  rest.  An  effective  combination  consists  of  five  grains  of 
chloral  hydrate  and  eight  grains  of  sulphonal.  Opium  and  bella- 
donna are  best  excluded  from  the  treatment.  Chloral  even  in  very 
small  doses  (three  grains  at  night)  sometimes  causes  headache  and 
lassitude  the  next  day — it  must  then  never  be  repeated.  In  uric  acid 
diathesis  and  marked  rheumatism  the  salicylate  of  soda  (ten  grains, 
t.  i.  d.)  often  produces  not  only  relief  of  any  existing  pain,  but  even 
sleep.  Sulphonal  and  trional  are  available  remedies  for  the  insom- 
nia, but,  like  the  chloral,  they  have  a  deleterious  influence  upon  the 
stomach,  and  should  be  preferably  given  per  rectum.  But  the  treat- 
ment producing  the  most  lasting  results  is  that  which  tones  up  and 
invigorates  the  neuromuscular  apparatus  and  the  nitrogen  elimina- 
tion and  increases  the  will  power. 


AUTHOR'S   SYNOPSIS    OF   SCHEME    FOR    EXAMINING 

STOMACH    PATIENTS    AT    THE    UNIVERSITY   OF 

MARYLAND  HOSPITAL. 

Medical  No....      Name Address Age...       Color 

Sex Social  Condition Diagnosis Date 


HEREDITARY  FACTS  OF  IMPORTANCE. 

PREVIOUS  HISTORY. — Severe  constitutional  diseases?  First  appearance  of  symptoms,  and 
cause?  Did  they  appear  suddenly  ?  Intensely?  Or  gradually?  Continuous?  Orremittent? 
What  intervals?  Occupation?  Habits?  Alcoholism?  Tobacco?  Cold?  Change  of  climate? 
Mental  strain?  Trauma?  Malaria?  Did  it  begin  with  or  without  a  chill?  Fever?  Yellow 
fever?  Constipation?  Diarrhea?  Dysentery?  Typhoid  fever?  Abdominal  diseases? 
Menstrual  irregularity?     Pregnancies? 

PRESENT  HISTORY. — Diseases  of  other  organs?  Pressure?  Local  and  subjective  complaints? 
Fullness?  Pain?  Distention?  Restlessness?  Sounds  in  the  digestive  tract?  Bowel  move- 
ments?    Nausea?     Eructation?    Vomiting?     Hematemesis?     Appetite?    Taste?    Thirst? 

LOCAL  SUBJECTIVE  SYMPTOMS.— Any  difficulty  or  pain  on  deglutition?  If  so,  its  regu- 
larity? Intensity?  Duration?  Pain  in  stomach?  Effect  of  food  on  pain?  Does  it  occur 
in  every  position  of  body?  Or  only  in  certain  positions?  Time  of  onset  after  meals?  Pain 
at  night?  On  an  empty  stomach  ?  Improved  by  eating?  Exaggerated  by  eating?  Is  pain 
diffuse?    Or  circumscribed?     Deglutition  sounds? 

ERUCTATION. — Duration?  Occurring  on  full  or  empty  stomach?  Is  gas  tasteless?  Odorless? 
Acid?     Decomposed?    After  what  foods  ?     Presence  of  pyrosis,  or  heartburn? 

NAUSEA  AND  VOMITING. — Occur  on  full  or  empty  stomach  ?  Frequency?  Taste  of  vomit? 
Appearance  of  matter?  Food  particles?  Proteids?  Starches?  Mucus?  Bile?  Pus?  Blood? 
Food  eaten  several  days  before?     Does  emesis  relieve  symptoms? 

APPETITE  AND  THIRST.— Accustomed  diet  (let  the  patient  state  in  detail  what  is  eaten  dur- 
ing the  entire  day)  ?     Mode  of  life?     Anorexia?     Bulimia?     Aversion  to  meat ?    Thirst? 

BOWELS. — Constipation?  Diarrhea?  Undigested  particles  of  food?  Mucus?  Pus?  Blood 
and  source? 

RESULTS  OF  BLOOD  EXAMINATION. 

GENERAL  NUTRITION.— Emaciation?     Loss  of  weight  in  pounds?     In  what  time? 

PHYSICAL   EXAMINATION. 

Examination  of  Tongue,  Teeth,  and  Mouth. 
INSPECTION. — Change  of  form  of  abdomen?    Tumor?    Gastric  or  intestinal  peristalsis? 
PALPATION. — Time   of  examination?     Temperature?     Outline   of  stomach?    Upper  border? 

Lower  border?     Presence  of  tumor?     Movement  of  tumor?     Was  stomach   full  or  empty? 

Pain  on  pressure?     Diffuse  or  circumscribed?    Succussion  sound?     Liver?    Kidneys? 
PERCUSSION.— Limits  of  the  stomach  ? 
DISTENTION  WITH    AIR   OR   GAS.— Limits   of  stomach?     Results   with   intragastric   bag? 

Does  tumor  move  with  distention  ?     Made  more  or  less  distinct  ? 
ELECTRODIAPHANY.— Limits  of  stomach?    Tumor? 

EXAMINATION   OF   TEST-MEALS. 

Double  tesl-meal  (see  p.  124) — a  full  meal  at  say  9  a.  m. 

Ewald  test-meal  at  say  2  p.  m.  Contents  drawn  at  say  3  p.  M.  Date, 

MACROSCOPICAL  EXAMINATION.— Quantity?     Color?    Odor?     Food  particles?     Froth  or 

gas?     Pus?    Mucus?     Bile?     Blood?     Fragments  of  tissue? 
MICROSCOPICAL  EXAMINATION.— Bacteria?     Oppler-Boas  bacilli?    Sarcinse? 
CHEMICAL   EXAMINATION.— Reaction?     Free   acid?     Free   HCl?     Lactic   Acid?     Amount 

freeHCl?     Combined  HCl?     Amount  acid  salts  and  organic  acids?     Total  acidity?     Erythro- 

dextrin?    Biuret  reaction?     Deficit  of  HCl? 

PEPSIN. 

Albumin   digested    in  pure  filtrate  in minutes.     Albumin  digested  in  acidified  filtrate  in.... 

minutes.    Albumin  digested  in  HCl  and  pepsin  filtrate  in minutes. 

RENNIN    OR    CHYMOSIN. 

Milk  coagulated  by  rennin  in minutes.     Milk  coagulated  by  rennin-zymogen  in minutes. 

Rennin-zymogen  active  in  dilution  i. 
CONTENTS. — After  meal  previous  evening  at  8  p.  M. 
CONTENTS. — After  lavage  previous  evening  at  8  P.  m. 
TIME  OF  SALOL  REACTION,. ..   minutes. 

TIME  OF  lODlD  OF  POTASSIUM  RESORPTION  TEST,. ...minutes. 
URINE.— Amount?    Urea?     Uric  Acid?     Reaction?    Indican?    Preformed  sulphates?    Albumin? 

Tube-casts?     Ethereal  sulphates  ?     Ratio?     Sugar?    Specific  gravity  ? 

TREATMENT. 

Diet?  Medicines?  Electricity?  Massage?  Hydrotherapy?  Lavage?  Mineral-spring  water  ? 
Gymnastics?     Results? 

873 


LIST  OF  AUTHORS. 


Compiled  by  the  author'' s  pupils,  Dr.  Henry  W.  Nolle  and  Mr.  Thomas  H.  Cannon. 


Abelmann,  fat  splitting  ferment  in  intes- 
tine, 55 

Abelous,  bacteria  in  the  stomach,  66 

Adler,  diseases  of  the  heart  and  the  stom- 
ach, 390 ;  congenital  atresia  of  the 
pylorus,  656  ;  diet  in  hyperacidity,  825 

Adler,  Harry,  carcinoma  and  Oppler-Boas 
bacillus,  565  ;  gastroptosis,  727  ;  hy- 
pertrophic stenosis,  614 

Albu,  autointoxication,  375,  795  ;  coma 
carcinomatosum,  560 ;  gastric  tetany, 
380 

Alt,  merycism,  766 

Ames,  phlegmonous  gastritis,  435  ;  carcin- 
omatous gastric  ulcer,  5  1 1 

Anderson,  nutritive  enemata,  208  ;  absti- 
nence cure  for  ulcer,  515 

Arnold,  cancer,  565 

Atkinson,  digestibility  of  foods,  226 

Atwater,  dietaries,  24 ;  effects  of  alcohol 
on  metabolism,  291 


Bachman,  W. ,  amylaceous  diet  for  hyper- 
acidity, 826 
Bachmeier,  floating  kidney,  726 
Baginsky,   pepsin  and  trypsin   interaction, 

70 
Bamberger,  gastromalacia,  488 
Bardenhauer,  median  hernia  and  gastral- 

gia,  797 
Bardet,  electric  therapy,  305 
Barie,  asthma  dyspepticum,  383 
Bartels,  gastric  inflammatory  atrophy,  450 
Barthez,  melaena  neonatorum,  684 
Baruch,  Dr.  Simon,  natural  mineral  waters, 

comparative  charts,  315  et  seq. 
Basch,  Seymour, gastralgia  in  tabic  patients, 

734 

Bauer,  rectal  alimentation,  213 

Beard,  electric  therapy,  304 

Beaumont,  peri.stalsis,  86,  87  ;  stomach  sur- 
gery, 340 

Beck,  cancer,  543 

Bensiey,  histology  and  physiology  of  the 
gastric  glands,  24 


Bernabes,  myoma,  609 

Bernard,  Claude,  pancreatic  juice,  59,  69; 

self-digestion  of  the  stomach,  487 
Berthelot,  steapsin,  60 
Best,  foreign  bodies  in  the  stomach,  6n 
Bettman,  H.  W.,  malformation  of  the  gas- 
tric cavity,  628,  642 
Beynard,  electric  stimulation,  304 
Biedert,  HCl  therapy,  332  ;   achylia,  848 
Biernacki,  kidney  diseases  and  the  stom- 
ach, 393        ..        . 
Bikfalvi,  alcohol  in  digestion,  294 
Billroth,  surgery,  350,  351,  363 
Bircher,  Dr.  Heinrich,  gastrorrhaphy,  650 
Blake,  Dr.  John  D.,  gastralgia  and  adhe- 
sions, 657,  798 
Blank,  digestion  of  fats,  64 
Boas,  peptic  gland  cells.  23  ;  ptyalin  diges- 
tion,  45;   duodenal  chyme,  69;   test- 
meal,    123  ;   bile  and  duodenal  secre- 
tion in  stomach  contents,  134;   epithe- 
lial exfoliation,  139,  141  ;   lactic  acid 
test-meal,    163 ;     analysis    for    HCl, 
method,    170  ;   lactic  acid  estimation, 
171  ;     pepsin    and    pepsinogen    tests, 
176  ;   rennin  and  rennin-zymogen  esti- 
mation, 17&;   dietetics,  194,  195,  261  ; 
nutritive  enemata,  207  ;  diet  lists,  234— 
248;    massage,  310  ;    alkali   therapy, 
339,  341  ;  gastric  surgery  and  secre- 
tion, 359  ;   asthma  dyspepticum,  383; 
infectious     gastritis,      438 ;     gastritis 
acida,    459  ;     ulcus    carcinomatosum, 
561  ;    autointoxication    in    dilatation, 
633  ;  rumination  with  subacidity,  766  ; 
gastralgia.  796  ;    gastric  crises,    832  ; 
achylia  gastrica,  850 
Bocci,  electricity,  peristalsis  and  secretion, 

304 
Bollinger,   glanders  in  the  stomach,  59°  j 

foreign  bodies.  612 
Booker,  W.  D.,   pathological   gastric   mu- 
cosa, 148  ;   acute  gastritis,  424 
Borissow,  confirmation  of  Schutz'  law,  54 
Borutteau,  secretion  and  peristalsis,  93 
Bottcher,  infectious  gastritis,  441  ;    gastric 

ulcer,  490 
Bouchard,  gastric  diseases  .and  respiration, 
377 


875 


876 


LIST   Olf   AUTHORS. 


Bouchert,  papain,  347 

Bouley,  absorption,  95 

Bouveret,  artificial  stomach  distention, 
104  ;  gastric  diseases  and  respiration, 
377  j  gastric  secretion,  151  ;  alcohol 
and  tetany,  1 94;  tetany  and  lavage, 
301,  380  ;  acute  gastritis,  422;  gas- 
tritis atrophicans,  460  ;  nervous  eruc- 
tation, 752;  bulimia,  807;  gastric 
crises,  832 

Brabazon,    gastric    inflammatory  atrophy, 

450 

Brandl,  gastric  absorption,  97 

Braun,  organic  acids,  analysis,  172 

Brenner,  gastroenterostomy,  351 

Brigham,  gastrectomy,  362 

Brinton,  gastric  glands,  25,  26  ;  peristalsis, 
88 

Broadbent,  Sir  Wra.  H.,  anorexia,  193; 
motor  insufficiency,  838 

Brock,  galvanism  and  gastric  neuroses,  308 

Brooks,  valvule  conniventes,  33 

Brown-Sequard,  the  stomach  in  nervous 
diseases,  386;  gastromalacia,  488 

Briicke,  pepsin  determination,  176 

Brunner,  peristalsis  testing,  75 

Bryant,  Joseph  D.,  cancer  statistics,  546 

Bunge,  HCl  an  antiseptic,  66 

Burkhardt,  dietetics,  209,  210,  251  ;  neur- 
asthenia gastrica,  S63 

Burton,  pancreatic  juice,  59 

Bush,  digestion  in  the  absence  of  the  usual 
ferments,  217 

C. 

Cabot,  Richard  C,  examination  of  gastric 

contents  for  blood,  137 
Cach,  power  of  stomach  in  living  animals 

to  split  up  neutral  fats,  53 
Cahn,  predigested  food,  211 
Cannon,  peristalsis,  89,  91 
Canstatt,  electric  therapy,  304 
Capelle,    foreign    bodies    in    the  stomach, 

612 
Captain,  gastric  bacteria,  66 
Cartellieri,  eructation,  752 
Charcot,  gastric  crises,  733;  anorexia,  812 
Chiary,  hour-glass  stomach,  644 
Chittenden.    Prof.    R.    H.,     saliva,    173; 

composition  of   beef   products,    201  ; 

alcohol  in  digestion,  292 
Chomel,  diet   in   dilation,    204 ;    dilation, 

.637 
Christomanos,  antiperistalsis,  215 
Church,  food  energy,  229 
Chvostek,  purulent  gastritis,  437 
Cohnheim,    Paul,  mucosa  fragments,    86; 

achylia  gastrica,  849 
Cohnheim,  ulcer,  489,490;   cancer,  542 
Colin,  absorption,  95 
Connor,  Dr.,  gastric  surgery,  349 
Contejean,  peristalsis  and  secretion,  93 
Cornil,  diagnosis  of  cancer,   564  ;   lymph- 
adenoma,  590  ;   polypi,  607 


Courvoisier,  gastro-enterostomy,  350 
Cruveilhier,  polypi,  608 
Cseri,  massage,  31 1 

Czerny,  resection,   350 ;   pyloroplasty  and 
resection,  365 


D. 

Daettwyler,  gastric  ulcer,  491 

Dauber,  antiperistalsis,  215 

Davis,  gastropexy,  366,  727 

Debove,  secretion  of  the  stomach,  151 

Decker,  gastromalacia,  489 

Deininger,  gastric  abscess,  437 

Deiters,  predigested  foods,  211 

Delafield,  acute  gastritis,  423 

Devic,    gastric    fermentation    and   tetany, 

194;  tetany  from  lavage,  301,  380 
Dobson,  Nelson  C. ,  ulcer,  516 
Dock,  George,  cancer,  562 
Donders,  dietetics,  187 
Donkins,  H.  B. ,   nutritive  enemata,   208; 

abstinence  cure  for  ulcer,  515 
Dreyer,  George  P.,  electrical  stimulation, 

Dubey,  hypertrophic  sclerosis,  445 
Duchenne,  electrotherapy,  305 
Dujardin-Beaumetz,  carbohydrates  in  hy- 
peracidity, 198  ;   dietaries,  223 
Duret,  gastropexy,  366,  727 


E. 

Earle,  Dr.  Samuel  T. ,  tuberculous  rectal 
fistula,  390 

Eberth,  carcinoma,  563 

Ebstein,  nervous  diseases  and  the  stomach, 
386  ;   gastromalacia,  488  ;•  polypi,  608 

Edinger,  L. ,  acute  gastritis,  423 

Edkins,  acid  and  formation  of  pepsin,  27  ; 
absorptions,  94 

Edsall,  D.  L. ,  gastrosuccorrhea,  84I 

Eichhorn,  subcutaneous  feeding,  221 

Eichhorst,  peristalsis  testing,  75  ;  spectro- 
scopic examination  for  blood,  137 ; 
rectal  alimentation,  213;  dietetics, 
240  ;   acute  gastritis,  428 

Einhorn,  Dr.  Max,  gastric  motor  function, 
74  ;  gastrograph,  78  ;  mucosa  exfolia- 
tions, 86  ;  gastrodiaphany,  107 ;  stom- 
ach bucket,  123;  erosions  of  the  stom- 
ach, 139,  142  ;  their  pathological  sig- 
nificance, 143  ;  gastric  secretion  in 
the  fasting  state,  151,  152;  intragas- 
tric spray,  302  ;  electrical  stimulation, 
304,  305,  307  ;  intragastric  electrode, 
305;  gastritis,  416 ;  electricity  in 
chronic  gastritis,  472 ;  trauma  and 
ulcer,  491  ;  hypertrophic  pyloric  ste- 
nosis, 613  ;  frequency  of  dislocated 
kidney,  718;  gastrosuccorrhea,  839; 
achylia  gastrica,  846,  850,  851 

Eiselberg,  von,  pylorectomy,  36 1 ;  phyto- 
bezoar,  613 


LIST  OF   AUTHORS. 


877 


Elsasser,  gastromalacia,  488 

Emmerich,  bile  action,  64 

Engel-Reimers,  cysts,  610 

Escherich,  bacteria  in  digestion,  65,  73 

Ewald,  capacity  of  the  stomach,  18;  fer- 
ment action,  46,  70;  peristalsis,  74; 
test-meal,  124,  125;  mucosa  exfolia- 
tions, 137,  142  ;  secretions  from  the 
fasting  stomach,  151,  152;  nutritive 
enemata,  213;  diet-list,  233,  240; 
massage,  310;  formula  for  anorexia, 
342;  tetany,  381  ;  nervous  diseases 
and  the  stomach,  386  ;  abscess,  437  ; 
gastromalacia,  489  ;  syphilitic  ulcer, 
601  ;  foreign  bodies  in  stomach,  61 1  ; 
fatal  gastric  hemorrhage,  686 ;  bu- 
limia, 804 


Faber,  absorption,  96 

Faust,  action  of  pepsin  on  proteids,  178 

Fenwick,  Samuel,  insufficiency  of  secre- 
tion, 330 ;  gastric  inflammatory  atro- 
phy and  anemia,  849 

Fenwick,  W.  Soltau,  poisoning  by  lavage, 
300 ;  pulmonary  diseases  and  the 
stomach,  388;  melsena  neonatorum, 
684 

Fermaud,  gastritis  parasitaria,  441 

Finkler,  papain,  347 

Finney,  J.  M.  F.,  exploratory  laparotomy, 
692 

Fischer,  melsena  neonatorum,  685 

Fitz,  R.  H.,  phantom  tumor  and  dilation 
of  the  colon,  722 

Fleiner,  electrodiaphany,  loS  ;  test-meals, 
124,  125;  alcohol  and  tetany,  I94; 
carbohydrates  in  hyperacidity,  198 ; 
gastritis,  416;  sarcomata,  547 

Fleischer,  gastric  motor  function,  74;  per- 
istalsis, 76 ;  gastrodiaphany,  107 ; 
diet-list,  248 ;  HCl  combining  povv^er 
of  foods,  249;  gastritis,  416;  men- 
struation and  gastric  disturbances,  734 

Flexner,  Dr.  S.,  tubercular  ulcer,  591 

Fliess,  gastric  neuroses,  209 

Flint,  Austin,  HCl  as  a  medicinal  agent, 
330 ;  gastric  inflammatory  atrophy, 
450  ;  anemia  and  atrophy,  849 

Foote,  E.  M.,  ulcer,  516 

Foster,  gastromalacia,  488 

Fowler,  intravascular  feeding,  220 

Fox,  Wilson,  ulcer  cure,  513  ;  hyperacid- 
ity and  peptic  ulcer,  500 

Frankel,  A.,  asthma  dyspepticum,  384 ; 
fatal  gastric  hemorrhage,  686 

Frankel,  C. ,  acute  gastritis,  428 

Frerichs,  gastric  glands,  25 

Friedenwald,  Dr.  Julius,  acidities  after 
test-meals,  125,  126;  toxic  products 
in  gastric  diseases,  377,  633 

Fubini,  electricity,  peristalsis,  304 

Fiitterer,  Gustav,  peptic  ulcer,  510;  etiol- 
ogy of  gastric  carcinoma,  540 


G. 

Gaff  ky,  infectious  gastritis,  439 
Galeotti,  diagnosis  of  cancer,  564 
Gartner,  bacillus  of  melena,  684 
Gerhardt,  C.,  eroded  mucosa,  138;   ulcer, 

289  ;  gastritis  parasitaria,  441 
Gersung,  dietetics  in  stenosis,  206 
Gessner,  bacteria  as  ferments,  65 
Gillespie,  interaction  among  bacteria,  66  ; 
gastric    motor    function,    75  ;     gastric 
douche,    725  ;     absorption    from    the 
stomach,  745 
Glaevecke,  absorption  of  iron,  812 
Glax,  purulent  gastritis,  435 
Gluczinski,  test-meal,  123 
Gmelin,  tryptophan,  61  ;  bile  test,  134 
Goldschmidt,    electricity,    peristalsis,   and 

secretion,  309 
Golgi,  mucosa  histology,  24 
Gombauldt,  hypertrophic  sclerosis,  445 
Graaf,  Regnier  de,  intestinal  contents,  55 
Gros,  Dr.  A.  P.,  rest  of  the  digestive  or- 
gans, 287 
Griitzner,  digestive   action   of  the  succus 
entericus,  72  ;  rectal  alimentation,  213, 
214 
Grynfelti,  melsena  neonatorum,  684 
Gull,  anorexia,  81 1 
Gussenbauer,  gastric  surgery,  349- 


H. 

Haberkant,    Dr.,     gastric     surgery,    349; 
statistics  on  surgical  operations,  355> 

371,374 
Habershon,    statistics    on    gastric    ulcer, 

494 
Hacker,  von.  gastro-enterostomy,  351,  353, 
360,    364  ;     gastro-anastomosis,    367  ; 
surgery  for  ulcer,  516;  NaCl  infusion 
for   gastric    hemorrhage,    5^7  >    hour- 
glass stomach,  644 
Haeberlin,  cancer  statistics,  546 
Hahn,  gastrolysis,352  ;  surgical  treatment, 

360, 364 
Haig,    Alexander,    rest   of    the   stomach, 

288  ;  gout  of  the  intestines,  392 
Halliburton,  W.  G.,  pancreatic  juice,  59 
Halliday,  Andrew,  merycism,  765 
Hamilton,  Dr.   Alice,  tuberculous  ulcers, 

593 
Hammarsten,    rennin-zymogen    test,    $1  ; 

comp  )sition  of  bile,  62  ;  bile  action,  69 
Hammerschlag,  test  for  peptonizing  power 

of  gastric  juice,  175 
Hanni,  HCl  therapy,  332 
Hanot,  hypertrophic  sclerosis,  445 
Hansemann,  mitosis  in  diagnosis  of  cancer, 

564  ;  tumors,  613 
Hartung,  mucosa  fragments,  138 
Hauser,  cancer,   542  ;    ulcus  carcinomato- 

sum,  560 
Hay  em,  mucosa  pathology,  142  ;   anemia, 

chlorosis,  and  gastric  diseases,  387  ; 


878 


LIST    OF   AUTHORS. 


"  gastrite  hyperpeptique,"  840;  achylia 
gastrica,  851 
Hehner  Seeman,  organic   acid   estimation, 

172 
Heidenhain,  peptic   gland-cells  and    their 
secretions,   22,   23,   24,   48 ;    function 
of  bile,  63 
Heinecke,  von,  pyloroplasty,  364;    puru- 
lent gastritis,  438 
Heinsheimer,  metabolism  in   gastro-enter- 

ostomy,  370 
Hemmeter,  Dr.  John  C. ,  duodenal  intuba- 
tion, 56;  intestinal  putrefaction,  68; 
gastric  motor  function,  74  ;  peristalsis, 
78,  90,  94 ;  gastrograph,  intragastric 
stomach-shaped  rubber  bag,  80,  82, 
86,  92;  test  for  absorption,  97-100 ; 
entero-  and  gastro-diaphany,  108, 
III,  114;  double-current  stomach- 
tube,  118  ^/'  seq.  ;  acidity  after  test- 
meals,  126 ;  significance  of  mucosa 
exfoliations,  143-147  ;  digestibility  of 
foods,  189  ;  digestion  of  enemata, 
215  ;  dietaries,  234,  238  ;  alcohol  and 
gastric  motility,  295  ;  electric  stimula- 
tion, 306  ;  formula  for  anorexia,  341  ; 
gastrectomy,  362  ;  gastric  tetany,  382  ; 
kidney  disease  and  the  stomach,  393  ; 
phlegmonous  gastritis,  435 ;  chronic 
hypertrophic  gastritis,  445  ;  electricity 
and  chronic  gastritis,  472 ;  gastro- 
malacia,  487 ;  fish-hook  f'orm  of  car- 
cinomatous gastric  ulcer,  51 1  ;  gastric 
ulcer  treatment,  513  ;  cancer  statistics, 
547 ;  ulcus  carcinomatosum,  561  ; 
carcinoma,  early  diagnosis,  566  ;  duo- 
denal intubation,  622,  641,  669; 
Rontgen-ray  photography  of  the  stom- 
ach, 640;  determination  of  length  of 
the  esophagus,  654 ;  pathogenesis  of 
enteroptosis,  704 ;  histology  of  stom- 
ach-glands in  hyperacidity,  732  ;  ab- 
sorption of  iron,  812;  proliferation  of 
glandular  elements  in  hyperacidity, 
814;  hyperacidity,  819;  achylia  gas- 
trica, 855;  merycism,  766;  pyloric 
sounding,  770 ;  schema  for  examina- 
tion of  stomach  patients,  873 

Hemmeter,  Mrs.  J.  C,  dietetics,  283 

Henoch,   asthma   dyspepticum,   382;     the 
tongue  in  chronic  gastritis.  456 

Henry,  red  corpuscles  in  carcinoma,  405  ; 
gastric  atrophy  and  anemia,  850 

Hensen,    Hans,   bacterial  invasion  of  the 
digestive  tract,  67 

Herschel,  absorption,  96 

Herter,  nervous  dyspepsia,  864 

Heryng,  transillumination,  108,  109 

Herz,    malaria    and    gastric    hemorrhage, 
.683 

Hildebrandt,  gastritis  parasitaria,  441 

Hippocrates,  dietetics,  187 

Hirschler,  carbohydrates  and  putrefaction, 

Hodder,  intravascular  feeding,  220 


Hodge,  C.  F. ,  effect  of  electricity  on  nerve 

elements,  303 
Hoffmann,  secretion  in  the  jejune  stomach, 

150,    152 ;     electricity  and    secretion, 

304  ;   gastritis,  447 
Hofmeister,  peristalsis,  86 
Honigman,  dietetics,  196  ;    HCl    therapy, 

331 
Hoppe-Seyler,  gases  in  the  stomach,  406; 
effect  of  exanthematous    diseases   on 
the  gastric  mucosa,  416 
Horaer,  gastralgia  and  lipoma,  797 
Howell,   W.    H.,    amylolysis,  46;    peris- 
talsis, 87 
Huber,  peristalsis  test,  76;    gastric  secre- 
tion,   151,    152;    rectal    alimentation, 
213;   dietetics,  240 
Hiifler,  gastrodiaphany,  107 
Hunter,  autodigestion  of  the  stomach,  487 
Huseman,  infectious  gastritis,  439 
Hutchinson,   pulmonary  diseases  and    the 
stomach,  388 


J- 

Jacobson,  diaphany,  109,  no 

Jaksch,  von,  rectal  contents,  71  ;  detection 
of  blood,  137  ;  carbohydrates  and 
hyperacidity,  198;  on  the  diazo  re- 
action, 428  ;  coma  carcinomatosum, 
560 

Jaworski,  rennin  test,  51  ;  colon  contents, 
71  ;  test-meal,  123  ;  secretion  stimu- 
lation, 152  ;  secretion  and  peristalsis 
after  gastric  operations,  359  ;  catarrhus 
acida,  840  ;   achylia  gastrica,  849 

Johnson,  Dr.   R.  W.,   gastric  surgery,  838 

Johnson,  Wyatt,  acute  gastritis,  428 

Jones,  Allen  A.,  gastric  secretion,  152; 
electrotherapy,  308 ;  renal  diseases 
and  the  stomach,  393  ;  anacidity,  850  ; 
gastralgia,  597 

Jones,  Bence,  urinary  changes  in  stomach- 
diseases,  408 

Jiirgens,  nervous  dyspepsia,  861 

Jiirgensen,  Chr.,  amylaceous  diet  in  hyper- 
acidity, 826 

Justesen,  J.,  am)laceous  diet  in  hyper- 
acidity, 826 


K. 

Kaiser,  surgery,  349,  569 

Kansche,    surgical    treatment,     secretion, 

and  peristalsis,  359 
Karst,  subcutaneous  feeding,  221 
Kaufman,  Oppler-Boas  bacillus,  132 
Kazzander,  valvulae  conniventes,  33 
Keen,  Prof.  W.  W.,  gastric  surgery,  35 1, 

674  ;  ulcer  statistics,  516;  gastropexy, 

727 
Kelly,  Dr.  H.  A.,  gastric  surgery,  759 
Key,  Axel,  ulcer,  490 
Kinnicutt.    F.    P.,    gastric     atrophy     and 

anemia,   330,   850 


LIST   OF   AUTHORS. 


879 


Klebs,  ulcer,  489 ;  cancer,  542  ;  infectious 

granulomata,  593 
Klein wachter,  acute  gastritis,  430 
Kleinperer,  fatty  acids  in  excessive  gastric 
fermentations  in  dilated  stomachs,  52  ; 
peristalsis,    74;    7^ ;    test-meal,   123; 
acute  gastritis,  423 
Klikowicz,  alcohol  in  digestion,  294 
Knapp,   uterine  displacements  as  a  cause 
of    nephroptosis,    712 ;    frequency  of 
dislocated  kidney,  718 
Koch,     nervous     diseases     affecting     the 

stomach,  386  ;  gastromalacia,  489 
Kolliker,  gastric  glands,  25 
Kooyker,   foreign  bodies  in  the  stomach, 

612 
Korczynski,  catarrhus  acida,  840 
Kramer,  stomach  operations,  359 
Kraus,  the  mouth  in  gastritis,  456 
Kretschy,   menstruation    and    gastric    dis- 
turbances, 734 
Krompecher,  cancer-diagnosis,  563 
Krueg,  subcutaneous  feeding,  221 
Kuhn,  F.,  absorption,  98  ;    HCl  action  on 
yeast,    153;  predigested   foods,   211  ; 
gases  in   the    stomach,   406  ;    pyloric 
sounding,  641 
Kiihne,  trypsin  and  pepsin  interaction,  70 
Kundrat,   infectious  gdstritis,  440  ;    sarco- 
mata, 548  et  seq. 
Kupffer,  border  cells  in  fundus,  23 
Kussmaul,  alcohol  and  tetany,  194;  diet  in 
dilation,   204;    gastric    douche,   301  ; 
electric  therapy,  305  ;   gastric  tetany, 
380 ;   stenosis  of  the  duodenum,  659 
Kuttner,  diaphany,  109,  iio;   gastric  sur- 
gery, 351 


Lambl,  polypi,  607 

Lancaster,  fatal  gastric  hemorrhage,  68 1 

Landau,     splanchnoptosis,     715;     melaena 

neonatorum,  683  ;   etiology  of  floating 

kidney,  694;   intestinal  stenosis,  717 
Landenberger,  hypodermic  feeding,  221 
Landois,  dietetics,  222 
Langerhans,   reco^^nition    of    gastroptosis, 

106  ;   etiology  of  enteroptosis,  700 
Langermann,  HCl  therapy,  332 
Langley,  ferment  and  acid  cells,  27;  pepsin 

and  trypsin  interaction,  70 
Larrey,  stomach  surgery,  349 
Lauenstein,  gastro-enterostomy,  350  ;   gas- 

trolysis,  352 
Lauterbach,  asthma  dyspepticuni,  383 
Lebert,  infectious  gastritis,  439 
Legroux,   transfusion    for    hemorrhage    in 

ulcer,  517 
Lemoine,  alkali  therapeutics,  336 
Leo,  secretions  in  the  fasting  stomach,  15 1; 

estimation   of   HCl,    169;    estimation 

of  fatty  acids,  172  ;  bulimia,  804 
Leonard,  diagnosis  of  renal  calculus,  801 


Leroy, transfusion  in  hemorrhagic  ulcer,5l7 

Letulle,  ulcer,  490 

Leube,  peristalsis,  74 ;  test-meal,  123  ; 
gastric  secretion  test,  152  ;  nutritive 
enema,  213  ;  subcutaneous  feeding, 
221  ;  dietaries,  243  ;  alkali  therapy, 
336 ;  gastric  and  intestinal  vertigo, 
378  ;  acute  gastritis,  429  ;  gastric  ab- 
scess, 437  ;  gastromalacia,  488  ;  ulcer 
cure,  514  ;   nervous  dyspepsia,  S60 

Leven,  nervous  dyspepsia,  863 

Levertin,  absorption,  100 

Lewin,  bacterial  invasion  of  the  walls  of  the 
digestive  tract,  67 

Leyden,  dietetics,  196,  206;  alcohol  and 
metabolism,    290 ;  juvenile   vomiting, 

757 
Leydig,  gastric  glands,  25 
Lindner,  gastric  surgery,  351 
Linossier,  therapeutics  of  alkalies,  236 
Litten,   chri'nic   gastritis,  460 ;   dislocation 

of  the  kidneys,  708 
Littmann,  papain,  347 
Lobker,     pyloroplasty    and    pylorectomy, 

365 

London,  ulcer,  489 

Loreta,  digital  divulsion  of  pylorus,  365 

Loye,  electrical  stimulation,  304 

Lubarsch,  O.,  insufficiency  of  gastric  se- 
cretion, 331  ;   achylia  gastrica,  846 

Lucksdorf,  bacteria  of  mouth  and  intestine, 
66 

Ludwig,  electricity  and  the  motor  func- 
tion, 304  ;  mineral  springs,  315  (t  seq. 

Liittke,  HCl  determination,  168 


M. 

MacDonald,  gastrectomy,  362 

Macfayden,  bacteria  in  economy  of  diges- 
tion, 65  ;   ileum  contents,  70 

Macleod,  abscess,  436 

Magendie,  vomiting,  754 

Maisoneuve,  surgery,  350 

Malbranc,  gastric  douche,  301 

Mall,  F. ,  anatomy  of  the  stomach,  17; 
peptic  gland  cells  and  their  secretion, 
23,  25,  27,  94;  antiperistalsis,  218 

Maly,  HCl  formation,  48;  bile  and  putre- 
faction, 64 

Mannaberg,  sustenance  of  colon  bacteria, 

73 
Marcet,    fat    splitting    ferment    in    normal 

stomach,  53 
Marfan,   stomach    in  pulmonaf-y  diseases, 

388 
Martin,     interaction     of     secretions,     70 ; 

gastric    absorption,   97  ;    detection    of 

sarcinx,  131  ;   gastritis,  416;   anthrax 

gastritis,  440  ;   ulcerations,  491 
Martins,  secretions  in  the  fasting  stomach, 

150,   151;    HCl   determination,    168; 

insufficiency  of  secretion,  331,  846 
Mathieu,  total  quantity  of  gastric  contents. 


88o 


LIST   OF   AUTHORS. 


152;    gastritis,    416;     acidity    of   the 

urine  and  gastric  contents,  816 
Mayer,  gastric  vertigo,  379  ;  autodigestion, 

488 
McCall,    treatment    of   ulcer    by   nutritive 

enemata,  208 
Meckel,  J.  E.,  vertical  position  of  stomach, 

695 
Mehring,  von,  starch   digestion,   46  ;  gas- 
tric absorption,   68,  94,   97,  99,   194; 
analysis  for  fatty  acids,  174 
Meinert,  acute  gastritis,  430 
Meisenbach,   foreign    bodies    in    stomach, 

613 
Meltzer,  S.   J.,   electrical  stimulation,  83, 
307 ;    absorption,    95  ;     electricity    in 
chronic    gastritis,     472 ;     subphrenic 
abscess,  512;   congenital  pyloric  ste- 
nosis, 656,  659 
Meltzing,  gastrodiaphany,  no 
Mendel,  alcohol  and  digestion,  292 
Mensche,  bitter  tonic  treatment,  341 
Menzel,  hypodermic  feeding,  221 
Merrem,  stomach  surgery,  349 
Meschede,  gastritis  parasitaria,  441 
Mesnil,  du,  alkali  therapy,  336 
Metschnikoff,  interaction  among  bacteria, 

66 
Meyer,  G.,  HCl  in  gastric  therapy,  330 
Michaelis,  gastric  hemorrhage,  517 
Michel,  gastric  hemorrhage,  517 
Mikulicz,    gastroscopy,    180;   statistics    in 
gastrectomy     and    gastrotomy,     354 ; 
pyloroplasty,  364 
Miller,  mouth   microbes,   66;   absorption, 

98,  99    _ 
Milliot,  transillumination,  107 
Minassian,  H.  A.,  merycism,  765 
Minkowski,  fat  splitting  ferment  in  intes- 
tine,   55  ;    bacteria   in    the    stomach, 
132  ;   dietetics,  204 
Mintz,   HCl    as    a    remedial    agent,    332  ; 

pylorectomy,  361 
Mitchell,  Weir,  fattening  rest  cure,  209 
Miura,  alcohol  as  a  food,  290,  291 
Morau,  HCl  in  gastiic  antisepsis,  66 
Moritz,   stomach  support,  19;  intragastric 
apparatus,  80,  86  ;   circulation  of  gas- 
tric ingesta,  92  ;   dietetics,  196 
Morris,  Henry,  gastrotomy,  353 
Moss,  analysis  of  a  man,  222  ;   percentage 

nutrition  of  foods,  226 
Mliller,  peptone  test,  179;   intestinal  auto- 
intoxication, 376 
Munk,  J.,  bile  and  absorption,  63  ;  prepar- 
ation of  food,  195 
Murphy,  surgery,  369 
Murray,  lipoma,  608 


N. 

Naunyn,  abnormal  retention  of  ingesta,  203 
Nencki,  bile,  agency  of,  in  pancreatic  diges- 
tion, 63  ;  fat  decomposition,  64;   bac- 


teria in  digestion,  65  ;  ileum  contents, 
70 

Neubauer,  absorption,  lor 

Neumeister,  schemata  of  digestion  :  amylol- 
ytic,  46;  proteolytic,  49,  61  ;  biliary 
diastatic  ferment,  63 

Noorden,  von,  deficiency  of  gastric  juice 
and  health,  330;  HCl  therapy,  331 ; 
malnutrition,  375  ;  gastric  crises,  755, 
832 

Nothnagel,  antiperistalsis,  214,  215  ;  in- 
sufficient secretion,  330 ;  gastric  in- 
flammatory atrophy,  450 

Novarro,  gastro-enterostomy,  368 

Nuttal,  bacteria,  not  essential  to  digestion, 
65 


Obalinski,  secretory  and  motor  functions 
as  affected  by  surgical  operations,  359 

Ogata,  albumin  as  food,  211 

Oppel,  anatomy  of  the  stomach,  17  ;  gas- 
tric glands,  25  ;  achylia  gastrica,  855 

Oppler,  gastrodiaphany,  ill;  sarcinse, 
131 ;  asthma  dyspepticum,  383  ;  achy- 
lia gastrica,  852 

Oppolzer,  gastromalacia,  488 

Orth,  acute  gastritis,  423  ;  infectious  gas- 
tritis, 440;  gastritis  polyposa,  446; 
carcinoma,  528  et  seq. ;  infectious 
granulomata,  590 

Oser,  infectious  gastritis,  438  ;  faradic  cur- 
rent in  gastralgia,  802 

Osier,  gastric  atrophy  and  pernicious  an- 
emia, 330,  850 ;  carcinoma,  369  ;  acute 
gastritis,  417,429;  chronic  gastritis, 
450 ;  abdominal  tumors,  554,  556, 
558;  tubercular  ulcer,  592  ;  dilation, 
636;   splanchnoptosis,  718 

Olt,  infusion  treatment  for  ulcer,  517 


Pancanowski,  location  of  the  stomach,  777 

Panecki,  gastralgia  and  the  uterus,  797 

Panum,  gastromalacia,  488 

Park,  Roswell,  cancer,  544 

Pasteur,  bacteria  in  digestion,  65 

Pavy,  self-digestion,  487 

Pawlow,  innervation  of  gastric  glands,  48, 
736  ;  secretory  nerve  of  pancreas,  48  ; 
law  of  Schutz  confirmed,  54 ;  gastric 
secretion,    199 

Pean,  resection,  350 

Pedioux,  cutaneous  diseases  and  the  stom- 
ach, 397 

Penzoldt,  absorption,  96;  stomach-tube, 
118;  dietetics,  196,  205;  dietaries, 
230-233-  237,  243  ;  Wtter  tonics,  340  ; 
gastritis,  416  ;  dilation,  631  ;  hunger, 
811 

Pepper,  effect  of  electricity  on  peristalsis, 
304  ;   dilation,  636 

Perco,  hypodermic  feeding,  221 


LIST   OF   AUTHORS. 


88l 


Perry,  E.  C,  intestinal  stenosis,  717 
Petruscky,  tuberculous  ulcer,  5 '6,  594 
Pettenkofer,  bile-acid,  demonstration,  135 
Payer,  bulimia,  806  ;  gastralgia  and  genito- 
urinary diseases,  797 
Phaff,  bile,  62 

Pick,  secretion  in  the  empty  stomach,  150  ; 
gastritis,  417  ;   autointoxication  in  di- 
lation, 633 
Pitt,  lymphadenoma,  609 
Playfair,  fattening  rest  cure,  209 
Podwyssozki,  pepsin  production,  27 
Posner,  bacterial  invasion  of  bowel  wall, 

67 
Potain,  asthma  dyspepticum,  384 
Preuschen,  von,  melsena  neonatorum,  684 
Pribram,  gastric  vertigo,  379 
Prudden,  acute  gastritis,  423 


Quinke,       insufficient       secretion,       330  : 
chronic  gastritis,   450  ;    ulcer,  491 


Rachford,  digestion  in  the  duodenum,  330. 
Ranke,  bile,  62 
Ranvier,  lymphadenoma,  590 
Rauber,  villi,  34 
Reaumur,  stomach  contents,  56 
Reiche,  hour-glass  stomach  and  ulcer,  511 
Reichert,  alcohol  as  a  food,  290 
Reichmann,  transillumination,  109;  gastric 
secretion,    151  ;   HCl  as  a  medicinal 
agent,  332  ;  alkali  therapy,  337  ;  bitter 
tonics,    340 ;    gastrosuccorrhea,    830, 

834 

Remond,  stomach  secretion,  15 1,  152; 
hour-glass  stomach.  642 

Remsen,  Ira,  mineral  spring  water,  470 

Richards,  Mrs.  E.  II.,  rations,  227 

Richardson,  gastrectomy,  362 

Richet,  acid  and  pepsin,  27 

Rieder,  cancer,  562 

Riegel,  peristalsis  test,  75;  determination 
of  location,  size,  and  capacity  of  the 
stomach,  methods,  I06,  108;  test- 
meal,  123  ;  sarcinae,  131  ;  Oppler- 
Boas  bacillus,  132;  secretion  in  the 
fasting  stomach,  15 1;  nutritive  ene- 
mata,  208,  214;  predigested  foods, 
2H  ;  gastric  douche,  302;  massage, 
311  ;  hyperacidity  and  ulcer,  501  ; 
HCl  in  therapeutics,  331  ;  asthma 
dyspepticum,  382 ;  hypersecretion, 
828,  836 

Rillet,  meleena  neonatorum,  684 

Rindfleisch,  ulcer,  490 

Ritter,  gastromalacia,  489 

Roberts',  Sir  William,  effects  of  cooking 
on  food,  252;  "indications  of  the 
palate,"  253  ;  alcohol  in  digestion, 
294,  297,  299;   hyperacidity,  814 


Rockwell,  electrotherapy,  304 

Rohmann,   bile  and  intestinal    peristalsis, 

64 
Rokitansky,  gastromalacia,  4S8 
Rollet,  gastric  gland  cells,  22,  25 
Romeyn,  alcohol  and  metabolism,  291 
Rondeau,  myoma,  609 
Rosemann,  alcohol  and  metabolism,  290 
Rosenbach,  asthma  dyspepticum,  382 
Rosengarth,  Jos.,  pathogenesis  of  entero- 

ptosis,  700 
Rosenheim,  gastric  cells,  22;  stomach- 
tube,  119;  gastroscopy,  180,  183, 
186;  pancreatic  ferment,  217  ;  gastric 
douche,  301  ;  massage,  310  ;  secre- 
tion and  the  motor  function  following 
surgical  operations,  359;  gastritis,  416; 
chronic  gastritis,  450  ;  carcinomatous 
ulcer,  511,  561  ;  carcinoma  diet,  575  ; 
gastralgia  and  median  hernia,  797 
Rosenstein,  stomach  in  diabetes  mellitus, 

392 
Rosenthal,    hydrotherapy,   310  ;  anorexia, 

811  ;  gastroxynsis,  830 
Rosin,    secretion    in  the  jejune    stomach, 

150 
Rossbach,  gostroxynsis,  830 
Rossi,  electric  stimulation  to  secretion,  304 
Rotch,  acute  gastritis,  422 
Roth,  gastralgia  and  median  hernia,  797 
Roux,  W.,   proteids  and  carbohydrates  in 

hyperchlorhydria,  198 
Rummo,  carbohydrates  vs.  proteids  in  the 

treatment  of  hyperacidity,  198 
Runeberg,    artificial    stomach    distention, 

104 
Rupp,  resection,   362 
Ruysch,  cysts,  610 
Rydygier,  resection,  350 


Sachs,  achylia  gastrica,  854 

Salkowsky,  absorption  lest,  loi 

Salzer,  Henry,  test-meal,  124,  126 

Scammell,  relative  value  of  foods,  225 

Schafer,   absorption  of  fats,  60 

Schech,  the  mouth  in  gastritis,  457 

Scheperlen,  chronic  gastritis,  450 

Schetty,  acute  gastritis,  423 

Scheurlen,  fatty  acids  in  excessive  fermen- 
tations in  dilated  stomachs,  52 

Schiff,  pepsin  and  acid,  27  ;  gastric  ulcer, 
488 ;  stomach  in  nervous  diseases, 
386 

Schillbacb,  electricity  and  peristalsis,  304 

Schlatter,  gastrectomy,  362 

Schlesinger,  Oppler-Boas  bacillus,  132  ; 
sarcoma,  547 

Schmid,  H.,  nephroptosis,  714 

Schmidt,  Adolph,  digestibility  of  mucus, 
133;  mucosa  in  gastric  diseases,  I48; 
alcohol  and  metabolism,  291 

Schmidt,  F.,  gastric  fever,"  428 


IvIST   OF   AUTHORS. 


Schmitt,    John,    frequency    of    dislocated 

kidney,  718 
Sciionborn,  foreign  bodies  in  the  stomach, 

611 
Schreiber,  secretions  in  the  fasting  stomach, 
150,  151,  836  ;  dilation,  458  ;  gastro- 
succorrhea,  834 
Schreiner,  Dr.  E.  R.,  diet-list,  194 

Schuchardt,  pylorectomy,  361 

Schiitz,  a  law  relating  to  tlie  proportion  of 
digestive  products  to  gastric  ferments, 
54  ;   peristalsis,  86 

Schwartz,  infusion  of  salt  solution  in  hem- 
orrhage from  ulcer,  517 

See,  Germain,  test-meal,  123  ;  alkali  treat- 
ment, 339 

Sehrwald,  physiology  of  cells,  23 

Seifert,  the  mouth  in  gastritis,  456 

Senator,  asthma  dyspepticum,  385  ;  gas- 
tritis parasitaria,  441 

Senn,  N.,  gastric  distention  with  hydro- 
gen, 368  ;   bone  plates,  369 

Shaw,  L.  E. ,  intestinal  stenosis,  717 

Sieber,  bacteria  in  the  digestive  economy, 
65,  72  ;  contents  of  ileum,   70 

Sievers,  gastric  motor  function,  75 

Silbermann,  asthma  dyspepticum,  382  ; 
ulcer,  489  ;  melasna  neonatorum, 
684 

Simon,  Chas.  E.,  indican  in  gastric  dis- 
eases, 199  ;  HCl  therapy,  333  ;  urine 
in  stomach-diseases,  41 1 

Smith,  E.  E.,  neurasthenia  gastrica,  864 

Sohlern,  von,  carbohydrates  vs.  proteids 
in  hyperacidity,  198 

Sohnan,  gastric  functions  affected  by  surgi- 
cal operations,  359 

Spalteholz,  gastric  anatomy,  17 

Stammreich,  alcohol  and  metabolism, 
291 

Stansfield,  gastro-enterostomy,  369 

Stein,  absorption  from  the  stomach,  745 

Stern,  stomach  in  heart-disease,  390 

Stewart,  D.  D.,  neuroses,  eftect  of  elec- 
tricity on,  308 ;  ulcus  carcinomatosum, 
561  ;  relation  of  anemia  to  gastric 
atrophy,  850 

Stiller,  enteroptosis,  700 ;  pylorospasm, 
744;  nervous  vomiting,  l^d;  hunger, 
803  ;   nervous  dyspepsia,  862 

Stintzing,  dietetics,  205 

Stockton,  Chas.  G.,  neuroses — electricity, 

305- 308 
Stokes,  chronic  hypertrophic  gastritis,  445 
Strauss,  Herman,  lavage,  123;  total  acid- 
ity, 126;   gastric  secretion,  152;   lac- 
tic acid  test,  170  ;  diet    in  hyperacid- 
ity, 825  ;  achylia  gastrica,  852 
Streit,  gastric  operations,  359 
Strieker,  ulcer,  487 

Strobe,  mitoses  in  gastric  carcinoma,  564 
Striimpell,  asthma  dyspepticum,  382 
Swieten,  von,  dilation,  204 
Swiezicki,  von,  cell  physiology,  23 
Swiezynski,  antiperistalsis,  215 


Talma,  hyperesthesia  toward   HCl,  33S  ; 

gastric  ulcer,  489 
Tanchou,  cancer  statistics,  544 
Tappeiner,  gastric  absorption,  95,  97 
Thierfelder,  bacterial  relation  to  digestion, 

Thomas,  T.  G. ,  intravascular  feeding,  220 
Thompson,  Gilman,  food  classes,  43  ;  die- 
tetics, 195  ;  intravascular  feeding,  283; 
dietetics    of    alcohol,     289  ;     mineral 
springs,  315  ^^  seq. 
Tinker,  ulcer  statistics,  516 
Topfer,  free  HCl  estimation,  165 
Treheux,  acidity  of  the  urine  and   gastric 

contents,  816 
Trousseau,  gastric  vertigo,  378 
Turck,  F.  B.,  bacteria,  130;  pyloric   intu- 
bation, 641 


U. 

Uffelmann,  lactic  acid  test,  163  ;   dietetics, 
195 


Vaughan,  fat  splitting  ferment  in  intestine, 

55 

Velden,  von  der,  secretion,  gastric,  in  neo- 
plasms, 550 

Virchow,  erosions  of  mucosa,  138;  ulcer, 
488,  489  ;  splanchnoptosis,  707  ;  en- 
teroptosis, 706 

Vogel,  absorption  test,  loi 

Voit,  bile,  62,  63 ;  rectal  alimentation, 
213 

Volhard,  fat  splitting  ferment  in  stomach, 
52,  54  ;  function  of  fat  splitting  fer- 
ment in  stomach,  53 

Vulpius,    gastralgia    and    median    hernia, 

797 


W. 

Waldeyer,  cancer,  540 

Wassmann,  gastric  glands,  25 

"Walther,  law  of  Schutz  confirmed,  54 

Weber,  guaiacum  test,  136  ;  electricity  as 
a  stimulus  to  peristalsis,  304 

Wegele,  dietetics,  196  et  seq.;  electric 
therapy,  305 

Weir,  Robert  F.,  ulcer,  516 

Welch,  William  H.,  chronic  gastritis,  45 1; 
ulcer,  494,  495  ;  carcinoma,  538 ; 
vicarious  hemorrhage  from  stomach, 
681  ;  nephritis  and  fatal  gastric  hem- 
orrhage, 683  ;  idiopathic  gastric  hem- 
orrhage, 685  ;   achylia  gastrica,  850 

Welti,  ulcer.  489 

Whitney,  Edward  L.,  gastric  absorption, 
loi  ;  chemistry  of  gastric  digestion, 
150  et  seq.;    the  blood  and  urine  in 


LIST   Olf   AUTHORS. 


883 


stomach-diseases,  401-414  ;  gases  of 

the  stomach,  405  ;  heterochylia,  866 
Whittaker,  subcutaneous  feeding,  221 
Widal,  acute  gastritis,  428 
Wiel,  dietetics,  195 
WiUiams,  pancreatic  juice,  70 
Winniwarter,  von,  surgical  treatment,  349 
Winslow,  Professor  Randolph,  gastroplica- 

tion,  366 
Wisting,  von,  bile  function,  63 
Wittich,  bile,  62 
Witzel,  gastrotomy,  353 
Wolff,     L. ,   bitter    tonics    and    secretion, 

340 
WSlfler,  surgery,  350,  363,  366 
Woltering,  dietetics,  196 
Woodruff,  C.  E.,  food  rations,  229 
Wurtz,  papain,  347 


Y. 

Yeo,  dietetics,  196  ;  food  energy,  228 
Yeo,  Burney,  gout  and  dyspepsia,  391 


Zabludowsky,  massage,  311,  313 
Zawadski,  secretion  and  peristalsis  in  sur- 
gery, 359 
Zawardsky,  pancreatic  secretion,  59 
Zesas,  gastrostomy,  354 
Ziegler,  acute  gastritis,  424,  435 
Ziemssen,  von,  gastric  secretion,  182  ;  elec- 
tricity   and    secretion,    304 ;     hydro- 
therapy,   310;     massage,    310 ;     gas- 
tritis, 472  ;   ulcer,  514 
Zweifel,    pancreas   diastase,    60 ;     gastric 
absorption,  96,  97 


58 


LIST  OF  SUBJECTS. 


Compiled  by  Dr.  Henry  W.  Nolte  and  Mr.  Thomas  H.  Ca^tnofi. 


A. 

Abdominal  rej^ulatory  center,  379 
Abscess,    gastric     (see     Gastritis,     Phleg- 
monous); subphrenic,  511 
Absorption  :  of  various  substances,  68  ;  de- 
pendence on  the  motor  func- 
tion,   73,    93 ;   variations    in, 
94 ;    testing   methods,  95  ;   a 
conditioning    factor    in    diet, 
191,193;  influence  of  alcohol, 
296 
Acetic  acid :   intestinal    fermentation,   64  ; 

analysis,  165 
Acetone,  412 
Achlorhydria,  846 
Achroodextrin,  45,  46 
Achylia  gastrica  :  nature  and  concept,  846 ; 
symptoms,    852  ;   patho- 
logical   histology,    854 ; 
etiology,  857;  treatment, 
858 
Acidity :    as    affected   by   test-meals,    and 
climatic,    barometric,    and    geo- 
graphic  factors,    124,    125,    126, 
127;    of  the    urine    and   gastric 
contents,  816 
Acids:    acetic,  64,   165;  action  of  succus 
entericus,    64 ;     amido-,    42,    64 ; 
asparaginic,  61  ;  aspartic,  61  ;  bile, 
69  (detection  in  stomach  contents), 
134;  butyric,  60,  64,  164;  caproic, 
65;  carbonic,   64;   diacetic,  412; 
fatty,  60,  64,  172;   fatty,  quantita- 
tive estimation  of,  172;  free  (tests), 
158 ;     hydrochloric    (see     Hydro- 
chloric Acid)  ;  lactic,  64,  132,  162, 
170,   171,565,   566;  nitrogen-free 
vegetable,   42  ;   organic    free,  48  ; 
organic    total    (estimation),    172; 
oxyacids,   64;    phenylacetic,    64; 
phenyl  propionic,  64;   skatol  car- 
bonic, 64;  stomach  acids  (analysis), 
165  ;  valerianic,  65 
Acoria,  80S 
Adenocarcinoma,  528 
Adenoma,  pedunculated,  610 
Albumin,  acid  (see  Syntonin) 
Albuminoid  decomposition,  71 


Albuminous  substances  (see  Proteids  and 
Albumins) 

Albumins  :  digestion — peptic,  48,49;  tryp- 
tic,  61,  62 
influence  on  biliary  secretion, 
62 ;  bile  action  on,  63  ;  re- 
lation to  succus  entericus, 
64 ;  in  treatment  of  hyperse- 
cretion and  hyperacidity,  196— 
200,  248,  249,  250 ;  in  urine 
the  result  of  gastric  disorders, 

413 

Albumoses,  65 

Alcohol :  in  food  substances,  42  ;  an  intes- 
tinal fermentation  product,  65  ; 
gastric  absorbability  of,  69;  diet- 
etics, 289;  effects  of,  on  meta- 
bolism, 291 ;  action  of,  on  peptic 
digestion,  292;  action  of,  on  pan- 
creatic digestion,  294  ;  action  of, 
on  salivary  digestion  and  on  the 
motility,  295  ;  absorption  affected, 
296 ;  summary  of  action,  296, 
297  ;  in  certain  pathological 
states,  297 ;  Sir  Wm.  Roberts' 
theory  in  respect  to  alcoholic  re- 
tardation of  digestion,  298 

Alimentation,  rectal  (see  Enemata,  Nutri- 
tive) 

Alkalies,  medicinal  agents,  335 

Alkalinity  of  the  blood,  403 

Alkaloids,  42 

Alveoli,  21 

Amidulin,  45,  46 

Ammonia,  64 

Amphopeptone,  49,  61 

Amylaceous  foods  in  hyperacidity,  196- 
200,  250,  825  ;  in  hy- 
persecretion, 250,  825 

Amylodextrin,  45,  46 

Amyloid  degeneration  of  the  stomach,  464 

Amylolysis :  bile  in,  69 ;  hyperchylia,  its 
influence  on,  821  ;  pancreatic, 
59  ;  ptyalic,  45-47,  63 

Amylopsin,  59,  70 

Anacidity  :  dietetics,  200  ;  indol  formation 
and  putrefaction,  334 

Anadenia  ventriculi,  846 

Analysis:   stomach  contents,  technic,   II6, 


886 


LIST   OF   SUBJECTS. 


117,  118;  meth- 
ods, 129 
quantitative   chemical,    153;    of 
gastric  juice,    158;  of  stomach 
acids,  165,  173 
Anemia  and  gastric   affections,   387,  513, 

849 
Anorexia,    nervous :     dietetics,    192 ;     the 

clinic  of,  811 
Antipeptone,  61 
Antiperistalsis,  2 13-21 5 
Antisepsis  of  the  digestive  tract,  47,   68, 

251 

Antizymotics    (see    agents     under     Anti- 
sepsis) 

Antrum  pylori,  18,  87 

Appetite,  anomalies   of  the    sensation  of, 
803 

Asthma  dyspepticum,  382 

Atony  : 

gastric,  myasthenic  :  terminology, 
etiology,  etc.,  624, 
625,  629  ;  differential 
diagnosis,  638,  639 ; 
prognosis,  642 ;  treat- 
ment, dietetic,  203, 
209,  237,  239,  644- 
65 1;  medicinal,  etc., 
644-646 
gastric,  neurotic :  definition  and 
etiology,  771-774; 
symptomatology,  775- 
778 ;  prognosis  and 
diagnosis,  778 ;  treat- 
ment, 778-783  (see 
Dietetic  under  Myas- 
thenic Type) 

Atresia,  642 

Atrophy  of  the  stomach,  846 

Auerbach,  plexus  of,  38 

Autochthonous  vegetation,  67 

Autodigestion,  gastric,  487 

Autointoxication,  intestinal,  67 


B. 

Bacteria:  fermentation  and  putrefaction, 
59)  65,  70,  72,  132  ;  economic 
and  pathogenic  significance,  66, 
68,  130-132;  species,  64,  66- 
72  ;  source  of  food  for  the  colon 
flora,  73 ;  analysis  of  stomach 
contents  for,  130,  131  ;  in  the 
walls  of  the  stomach,  130  ;  HCl 
and  peristalsis  as  related  to 
propagation  of,  130 ;  products 
giving  rise  to  pathological  con- 
ditions, 132 

Bag,  intragastric,  stomach-shaped,  of  Hem- 
meter,  80,  82-85,  93 

Basement  membrane,  35 

Bile  :  composition,  63  ;  uses  and  functions, 
62,  63,  69;   detection,  134 

Blood:    supply   to   the   stomach,    28-31 ; 


supply  to  the  intestines,  32,  34, 
37  ;  in  stomach  contents,  tests  for, 
135, 136  ;  in  gastric  diseases,  402- 

405 
Boas'  method,  analysis  of  stomach  acids, 

168 
Braun's  method,  172 
Bulb  for  aspirating  test-meals,  120 
Bulimia:     dietetics,     191  ;     nature,     S03  ; 
causation,    804 ;     symptomatol- 
ogy, 806 ;   diagnosis,  807  ;  treat- 
ment, 810 
Butyric  acid:   steapsin    digestion,    60;    in 
putrefaction,  64  ;    analysis, 
164 


Calcium,  42 
Cancer  (see  Carcinoma) 
Carbohydrates  :    economic    function,    42  ; 
effect  on  bile  efflux,  62  ; 
absorption  of,  in  presence 
of  bile,  63  ;  fermentation, 
64,  66,  70  ;  action  of  the 
succus  entericus,   72  ;   in 
hyperacidity    and    hyper- 
secretion,   196-200,  249, 
250,  825 
Carbolic  acid,  64 
Carbon,  41 

Carcinoma  :  germ  growth  in  walls  of  stom- 
ach in,  130;  blood  changes, 
405  ;  pathology,  527  ;  eti- 
ology, 541  ;  symptomatology, 
548-561 ;  diagnosis,  561-566 ; 
treatment,  205,  242,  568,  571, 
572,  576;  indications  for 
operation,  357 ;  prognosis, 
577  ;  differential  diagnosis  (see 
Table),  587;  adeno-,  528  ;  col- 
loid, 536;  duodenal,  558; 
medullary,  532 ;  pancreas, 
558  ;  scirrhous,  534 
Carcinomatous  degeneration  of  peptic 
ulcer,    509  ;    histologic    characteristics, 

Cardia  :  anatomy  of  the,  18  ;  carcinoma  of 
the,  566  ;  obstruction  of,  651  ;  ob- 
struction of,  forms  of,  652  ;  symp- 
tomatology, 653  ;  diagnosis,  653  ; 
prognosis,  654  ;  treatment,  654  ; 
cramp  of  the,  737  ;  incontinence 
of  the,  761 

Cardiospasm,  737 

Caroid,  347 

Casein,  51,  61  ;  peptones,  60 

Catarrh,  gastric,  236,  237,  444 

Cecum,  40 

Celiac  axis,  28  ;   plexus,  38 

Cells:  acid,  24;  adelomorphous,  22; 
anilin-staining,  24;  border,  22,  23, 
24,  27,  28  ;  central,  22-24,  27,  28  ; 
chief,    22-24,    25,    26;    columnar 


LIST   OF   SUBJECTS, 


887 


epithelial,  21,  32,  35;  cuboidal 
epithelial,  21  ;  cylindrical  epi- 
thelial, 22  ;  delomorphous,  23  ; 
eosinophilic,  35  ;  epithelial  of  villi, 
35  ;  ferment,  24 ;  goblet,  36 ; 
mucous  or  mucin,  21,  22,  26; 
neoplasm,  561  ;  Nussbaum's,  23  ; 
oxyntic,  22,  23;  parietal,  22,  23; 
pyloric  gland,  25 

Cerebral  vomiting,  754 

ChJorids  :  in  gastric  HCl  production,  49  ; 
in  urinary  changes,  408 

Chlorin,   42 

Chlorosis  and  gastric  diseases,  387 

Cholelithiasis,  508 

Chyme.  62,  68,  69 

Chyraosin  (see  Rennin) 

Cirrhosis  :    gastric,    614;    ventriculi,   445, 

553 
Clinic,  the  gastric,  415 
Clysters  (see  Enemata) 
Colon,  40;    diaphany,    108;  observations 

on  dislocation  of,  696 
Coloptosis,  722 
Coma  carcinomatosum,  559 
Constipation,  chronic,  dietetics  in,  247 
Convulsions  of  the  pylorus,  744;    of   the 

stomach,  746 
Cooking,  dietetical,  255 
Coprostasis,  707 
Coronaria  ventriculi  artery,  30 
Cramp  of  the  cardia,  737  ;  of  the  pylorus, 

744 
Creatin,  42 
Crises,  gastric,  754 
Cysts,  gastric,   610 


D. 

Deutero-alhumoses,  61 

Deuteroproteoses,  49 

Dextrin  :  digestion  product,  ptyalic,  45,  46, 
47  ;  amylolytic,  60  ;  absorption 
of,  69 

Dextrose,  45-47 

Diabetes  mellitus  and  state  of  the  stomach, 
392 

Diagnosis,  differential,  of  cancer,  ulcer, 
gastralgia,  hyperchlorhydria,  and  gas- 
tritis (see  Table),  587 

Diaphany  of  stomach.  107;  colon,  108; 
duodenum,  108;   ileum,  108 

Diarrhea,  chronic,  diet,  245-247 

Diastase  :  of  saliva,  44,  45  ;  in  bile,  63  ; 
of  pancreas,  60  ;  as  a  medicinal 
agent,  344 

Diazo  reaction,  Ehrlich's,  413 

Dietetic  exercise,  285 

Dietetics:  historical  retrospect,  187  ;  diges- 
tibility, 188  ;  gastric  functions 
conditioning  diet,  sensation, 
191  ;  absorption,  193;  secre- 
tion, 196  ;  motility,  203  ;  hyper- 
secretion and  hyperacidity,  196, 


200 ;    anacidity    or    subacidity, 
200;   ulcer,    197,   207;   gastritis 
acida,  197  ;   ulcus  carcinomato- 
sum, 197,  205  ;   atony  and  dila- 
tion,   203  ;     carcinoma,     205  ; 
neuroses,  209;  fattening  cures, 
209;    predigested    foods,    210; 
rectal  alimentation,  212  ;   intra- 
vascular and   hypodermic  feed- 
ing,   220;     tables    of    dietaries, 
222  ;   diet  lists,  230  ;  cooking  of 
food  and  the   palate,  252-256; 
rectal     enemata,     varieties     of, 
282  ;  alcohol  and  alcoholic  bev- 
erages, 289 ;   drinks  and  liquid 
foods,  256 
Diet   lists:     Fenzoldt's,  for    the    gradual 
training  of  the  digestive  ca- 
pacity,    230 ;     Ewald's    and 
Boas',     233 ;     Hemmeter's, 
chronic    gastritis,   etc.,  234; 
Wegele's,    chronic     catarrh, 
236;  Wegele's  gastric  atony, 
237?    239;   Hemmeter's,   for 
anacid    dilation,    238 ;   carci- 
noma,    242 ;      ulcer,     243 ; 
chronic  diarrhea,  245  ;  hyper- 
acidity, 248  ;  hypersecretion, 
249 ;      intestinal     antisepsis, 
neurasthenia,   and    neuroses, 
251  ;  and  dyspepsia  on  hys- 
terical basis,  251 
Digestion  :    alcohol  retardation  of,  theory 
of  Sir  William   Roberts,  298 
amylolytic,    44,    47,    60,    70 
fat,  60,  63  ;  intestinal,  55,  73 
822  ;   pancreatic,  59,  62,  294 
peptic,  47-52,  292,  296,  298 
proteolytic,    47-52,   61  ;     pty- 
alin,    44,   45,  63,    173,  .295  ; 
rennin,  51,  176,  177  ;  salivary, 
44,  45,    173  ;   starch,   45,  46, 
47,  60;   steapsin,  60;   tryptic, 
60,  61 
Digestive  disturbances  in  connection  with 

renal  diseases,  395 
Dilation,  gastric  :  classification  and  nomen- 
clature, 623,  624;  ob- 
structed form,  625  ;  dif- 
ferential diagnosis,  638, 
639 ;  prognosis,  642  ; 
treatment,  203,  237— 
240,  646,  651  ;  atonic 
form,  629;  differential 
diagnosis,  639 ;  treat- 
ment, 203,  238,  239, 
644,  651  ;  diagnosis  by 
gastrodiaphany,  109-111 
Dilator  pylori,  20 

Dimethyl-amido-azo-benzol  test,  159 
Disinfection  of  digestive  tract,  47,  68,  251 
Divulsion,   digital,  of  the  pylorus,  365 
Douche,  the  gastric,  301 
Drinks  and  li(|uid  foods,  256 
Duodenal    intubation,    56-59;     secretion. 


LIST   OF   SUBJECTS. 


interaction,  69,  70;  secretion, 
detection,  135 

Duodenodiaphany,  108 

Duodenum,  31,  32,  38 

Dyspepsia,  nervous  :  nature  and  concept, 
860  ;  pathology,  861  ; 
etiology,  862  ;  symp- 
tomatology,  863  ; 
prognosis,  865  ;  diag- 
nosis, 865  ;  hetero- 
chylia,  866  ;  differ- 
ential diagnosis,  867 ; 
treatment,   251,    867 


Elastin,  47,  61  ;   peptones,  47,  61 

Elastoses,  61 

Electric  stimulation  of  peristalsis,  83-86 

Electricity  in  gastiic  therapy,  302  et  seq. 

Electrodiaphane,  107 

Electrodiaphany,  107-114;  criticism  and 
limitations  of  the  method, 
IIO-114 

Electrode,  intragastric,  Einhorn's,  305 

Enemata  :  dilation,  204  ;  evolution  of,  212  ; 
ulcer,  207  ;  antiperistalsis,  214, 
215;  digestion  of,  216;  prepa- 
ration and  administration,  218, 
219;  indications  for  nutritive 
kind,  219;  kinds  of  nutritive, 
282 

Enterodiaphany,  108 

Enteroptosis :  etiology  and  symptomat- 
ology, 693-709 ;  historical 
view    of,    698  ;    treatment, 

723 
Enzymes  (see  Ferments) 
Epileptiform  convulsions,  380 
Erosions,  gastric,  dietetic  treatment,  207 
Eructation,  nervous,  751 
Erythrodextrin,  45,  46 
Esophageal  applicator,  185  ;  forceps,  185  ; 

tubal  probe,  123 
Esophagoscope,  185 
Ethereal  oils,  42 
Ewald  tube,  126 

Examination  of  stomach  patients,  schema, 
873 

F. 

Faradization,  306,  308 
Fascije  tenise,  40 

Fat  splitting  ferment  of  stomach,  52  ;  bac- 
teria as  cause,  52 ; 
physiology  of,   53 
Fats  :  economic  import,  43  ;   in  pancreatic 
digestion,  61  ;   effect  on  flow  of  bile, 
62  ;   bile  action,  63  ;  action  on  suc- 
cus  entericus,   64  ;  bacterial  action, 
64 
Fatty    acids:     pancreatic     digestion,    60; 
bacterial  product,  64;  anal- 
ysis, 172 


Feeding,  rectal  (see  Enemata,  Nutritive) 
Fermentation :    relation    to   the  economy, 
66  ;  products,  64,    70  ;   in- 
hibiting   agents,    130 ;    in 
gastrectasia,  153 
Ferments:    amylolytic,    44,    45,    59,    69, 
I73>  343;  amylopsin,   59,70; 
artificial,    343 ;     bacteria    (see 
Bacteria) ;     diastatic,    44,    45, 
60,     63,    344;     inverting    (of 
succus    entericus),    64;     milk- 
precipitating  (pancreatic),  59; 
pancreatic    diastase,    60 ;  pan- 
creatin  (medicinal  agent),  345  ; 
pepsin    (see    Pepsin);    pepsin- 
ogen (see  Proenzymes)  ;  pine- 
apple,   348 ;     proteolytic,    49, 
59,  215  ;  prozymogen,  25,  26  ; 
ptyalin,  44,  45,  64,  173,  343  ; 
rennin   (see  Rennin)  ;    rennin- 
zymogen     (see    Proenzymes)  ; 
steapsin,   60,   63  ;  trypsin,  61, 
69,  70,  71,  72,  73;  interaction, 
69,    73;  tests,    173;  in  urine, 

413 
Fibromata,  606 

Food  substance:  constituents  and  their  re- 
lation to  the  economy, 
41,  42;  food  groups  of 
Gilman  Thompson,  43; 
kinds  of  food  values,  43  ; 
combining  power  with 
HCl,  250;  drinks  and 
liquid  foods,  256 

Foreign  bodies  in  the  stomach,  610 

Fundus  of  stomach,  18 

Fungi  (see  Bacteria) 


G. 

Galvanization,  308 

Gases  :   acetylene,  405  ;  carbonic  acid,  64, 

405  ;  hydrogen,  41,  65,  405,  406; 
hydrogen  sulphid,  65,  405  ;  marsh, 

406  ;  methyl-mercaptan,  65  ;  ni- 
trogen, 405,  411  ;  oxygen,  405  ; 
"  stomach,"  153,  405 

Gastralgia :    description,   795;    causation, 
796;  types,  798,  799;   symp- 
tomatology,   799 ;    diagnosis, 
799  ;    differential    diagnosis, 
587  ;    treatment,    801  ;    idio- 
pathic, 798 ;  secondary,  798 
Gastralgokenosis,  803 
Gastrectasia  (see  Dilation,  Gastric) 
Gastrectomy,  362 

Gastric,  lipase,  52;  crises,  754;  diseases, 
influence  upon  other  organs  and 
metabolism,  375 ;  douche,  301  ; 
idiosyncrasies,  794  ;  juice,  physi- 
ology, 22,  47,  52;  stimulation, 
150;  chemical  examination,  158; 
periodic    atypical     flow     of,    830; 


LIST   OF   SUBJECTS. 


chronic  continuous  flow,  834  ; 
absence  of  secretion,  846 
Gastritis  :  definition  and  classification  of, 
415;  acida,  459;  dietetics,  196; 
anacida,  459  ;  atropliicans,  460  ; 
state  of  blood,  404;  diet,  234; 
mucosa  or  mucipara,  459  ;  poly- 
posa,  446 ;  syphilitic,  597;  ste- 
nosing,  613 

acute,  simple  :   nature    and  con- 
cept, 417  ;  etiol- 
ology,420;  path- 
ological     histol- 
ogy, 423;   symp- 
tomatology    and 
course,  426;     di- 
agnosis,       428  ; 
prognosis        and 
treatment,     429, 
430 ;       condition 
of  the  blood,  404 
infectious :     gastritis    infectiosa, 
438 ;     diphtheritica, 
439 ;  mycotica,  439  ; 
parasitaria,  440 
venenata,  44I 

phlegmonous  or  purulent,  435 
chronic :   concept      and      types, 
444 ;     etiology,     446  ; 
pathological  anatomy, 
448  ;  symptomatology, 
453 ;       complications, 
462 ;     atypical    forms, 
462;    diagnosis,    462; 
prognosis,  465  ;   differ- 
ential diagnosis,  587  ; 
treatment,     233,     234, 
465;  blood  changes  in, 
404 
Gastro-anastomosis,  366 
Gastrocolic  ligament,  41 
Gastrodiaphany    of  Einhorn,    107;   as    an 

aid  to  diagnosis,  1 14 
Gastrodynia  (see  Gastralgia) 
Gastro-enterostomy,  362,  363 
Gastro-epiploic  arteries,  30 
Gastro-gastrostomy,  366 
Gastrograph  of  Einhorn,  81  ;   of  Hemme- 

ter,  80,  82-84,  93 
Gastroliths,  61 1 
Gastrolysis,  352 
Gastromalacia,  487 
Gastropexy,  366 
Gastroplasty,  366 

Gastroptosis  :  observation  on,  695  ;   symp- 
tomatology, 721  ;  diagnosis, 
109,    no,   639,    722;    treat- 
ment, 723 
Gastrorrhagia   (see  Hemorrhage   from   the 

Stomach) 
Gastrorrhaphy,  354 
Gastrorrhexis,   634 
Gastroscope,  181 
Gastroscopy,  180 
Gastrospasm,  746 


Gastrostomy,  353 

Gastrosuccorrhea  periodica,  830  ;  chronica, 

834 

Gastrotomy,  353 

Gastroxie,  830 

Gastroxynsis,  830 

Gelatin,  47,  61,  63  ,  peptones,  47,  60 

Gelatoses,  61 

Glands  :  agminate,  36,  38  ;  Brunner's,  36; 
crypts  of  Lieberkiihn,  36  ;  gastric 
follicles,  21,  22;  lymph-follicles, 
36,  37  ;  mucous,  21  ;  peptic,  22, 
23,  27  ;  Feyer's  patches,  36,  38; 
pyloric,  27,  37  ;  salivary,  45  ; 
solitary,  36,  38 

Glenard's  disease,  613 

Globulin,  61 

Glucosids,  42 

Glycerin  60,  64 

Gmelin's  test,  134 

Gout  and  gastric  disease,  391 

Granulomatous  infections,  590 

Guaiacum  test,  135 

Gymnastics,  abdominal,  724 


H. 

Heart  :  disturbances  induced  by  gastric 
diseases,  376 ;  cardiac  diseases 
affecting  the  stomach,  390 

Hehner-Seeman  method  of  analysis,  172 

Hemialbumoses  (see  Propeptone) 

Hemipeptone,  61 

Hemoglobin,  402 

Hemorrhage  from  the  stomach,  680  ;  eti- 
ology, 680-686  ;  pathology, 
686  ;  symptomatology,  686  ; 
diagnosis,  689  ;  prognosis, 
692  ;   treatment,  692 

Hepatocolic  ligament,  40 

Hepatoptosis,  721 

Heterochylia,  866 

Heteroproteose,  49 

Hour-glass  stomach,  51 1,  642 

Hunger,  anomalies  of  the  sensation  of, 
803 

Hydrochloric  acid:  source,  22-24,  27,  28, 

47,  48  ;  derivation,  28, 
48  ;     action,     28,    47, 

48,  49,  334  ;  demon- 
stration, 50;  in  gastric 
antisepsis,  66,  130 ; 
interaction  among  se- 
cretions in  the  intes- 
tines, 69,  70  ;  tests  for 
HCl,  free,  159  ;  tests 
for  combined,  161 ; 
combining  capacity  of 
foods  with,  250; 
effect  of  alcohol  on 
pepsin  -hydrochloric 
acid  digestion,  292  ; 
as  medicinal  agent, 
329;     in     neoplasms, 


890 


LIST   OF   SUBJECTS. 


550,  551  ;  in  hyperse- 
cretion, 836 

Hydrogen,  41,  65 

Hydronephrosis,  717 

Hydrotherapy,  309 

Hyperacidity:  true  index  of,  126;  defini- 
tion and  types,  198-200 ; 
factor  in  bulimia,  192  ; 
dietetics,  197-200,  248, 
250;  combining  power  of 
various  foods  with  HCI, 
250  ;  relation  to  indican- 
uria,  334 ;  factor  in  ulcer, 
491  ;  the  clinic  of,  charac- 
teristics, 813  ;  etiology, 
818  ;  nature  and  concept, 
817  ;  symptomatology,  819  ; 
prognosis,  823  ;  diagnosis, 
823  ;  difierential  diagnosis, 
587  ;   therapeutics,  825 

Hyperchlorhydria  (see  Hyperacidity) 

Hyperchylia  (see  Hyperacidity) 

Hyperesthesia,  791  ;   dietetics,  209 

Hypermotility  as  factor  in  bulimia,  192  ; 
the  clinic  of,  746 

Hyperorexia  (see  Bulimia^ 

Hyperperistalsis,  748 

Hyperplasia,  inflammatory,  448 

Hypersecretion,  chronic,  834 ;  dietetics, 
196,  249, 250 

Hypochlorhydria,  843 

Hypochylia,  843 


Icterus,  catarrhal,  analysis  of  stomach  con- 
tents in,  391 
Idiopathic  gastralgia,  798 
Idiosyncrasies,  gastric,  794 
Ileodiaphany,  108 
Ileum,  40 

Inacidity,  nervous,  846 
Incontinence  of  the  cardia,  761  ;   pylorus, 

768 
Indican,  66, 199,  334 
Indicanuria,  334 
Indicators,  154,  156 
Indol,  61,  64,  334 
Inflammation  of  the  stomach,  suppurative 

(see  Gastritis,  Phlegmonous) 
Innutritious  materials   in  food   substances, 

41,  42 
Insufficiency  of  the  cardia,  761  ;  of  the  py- 
lorus, 768 ;    of   the  stomach, 
mechanical,  771  ;  motor,  634 
Intestinal  digestion,  55-73,  130,  822  ;   fer- 
mentation,   64,    66,    70,     130; 
putrefaction,  64,  65,  71,  130 
Intestine:   anatomy  of  small.    31-41  ;    of 
large,  40  ;   duodenal  intubation 
of  Hemmeter,    56-59;    entero- 
diaphany,     108;      autointoxica- 
tion and  disinfection,  67,  68 


Intragastric  stomach-shaped  bag  of  Hem- 
meter,  56-59 
Inulin,  60 
Iron,  42,  136 
Ischochymia,  650 


Jejunum,  3 1,  40 


K, 

Karyokinesis  in  neoplasms,  527 

Kerkring,  valves  of,  ^;^ 

Kidneys :  diseases  of,  and  the  state  of  the 
stomach,  392 ;  dislocation,  in 
gastroptosis  and  enteroptosis, 
708  ;  floating  and  movable,  709  ; 
etiology  of,  694  ;  palpation,  bi- 
manual, 712  ;  diagnosis  of  pal- 
pable, movable,  and  dislocated 
kidney,  716;  treatment,  726  j 


Lacteals,  32,  34 

Lactic  acid  :  intestinal  fermentation,  64  ; 
bacterial  gastric  product, 
132  ;  origin,  significance, 
and  detection,  162  ;  quanti- 
tative estimation,  170,  171; 
diagnostic  value  in  cancer, 
564 ;  conditions  necessary 
for  excessive    formation    of, 

565 

Laparotomy,  exploratory,  358 

Lavage :  d  o  u  b  1  e-current  stomach-tube, 
I16-121;  contraindications,  121, 
122;  in  dilation,  204,  205;  in- 
dications for,  etc.,  299 

Leo's  method  of  analysis  of  stomach  acids, 
169 

Leucin,  61,  64 

Leukocytosis,  402 

Levulose,  47 

Ligamenta  coli,  41 

Lipoma,  608 

Literature:  on  gastrodiaphany,  I15;  on 
the  history  and  technics  of  the 
stomach-tube,  127  ;  exfolia- 
tions and  erosions  of  gastric 
mucosa,  140;  correlation  of 
diseases  of  the  stomach  to  those 
of  other  organs,  399 ;  acute 
and  chronic  gastritis,  478 ; 
phlegmonous  gastritis,  482 ; 
ulcer,  518  ;  carcinoma,  577  ; 
gastric  tuberculosis,  595  >  S^'^' 
trie  syphilis,  605;  hypertrophic 
stenosis  of  the  pylorus,  622 ; 
congenital  hypertrophic  ste- 
nosis of  the  pylorus  in  infants, 
662 ;  dilation,  674 ;  gastro- 
ptosis and   enteroptosis,  727  ; 


LIST   OF   SUBJECTS. 


neuroses,  783 ;  chronic  gas- 
trosuccorrhea,  841 

Liver,  observations  on  dislocation  of,  697 

Liver-diseases  and  the  stomach,  391 

Lumbago,  721 

Lymphadenoma,  609 

Lymphangioma,  610 

Lymphatics  of  stomach,  29,  30;  of  intes- 
tines, 32,  34,  38 

Lymph-corpuscles,  ameboid,  36 

Lymphoid  tissue,  34,  36 


M. 

Macrocytes,  512 

Magnesium,  42 

Malaria,  386 

Maltose,  44-47,  60,  68 

Martius  and  Liittke's  method  of  analysis  of 
stomach  acids,  168 

Massage,  310-313  ;  and  medicated  irriga- 
tion, technic  of,  313 

Materia  medica,  187  et  seq.,  329 

Medicinal  agents,  important :  HCl,  329  ; 
alkalies,  335 ;  bitter 
tonics,  339 ;  digestive 
ferments,  343 

Megalogastria,  623 

Meissner,  plexus  of,  34,  38 

Melena  in  carcinoma,  560,  566 

Merycism,  764 

Mesenteric  plexus,  38 

Metabolism,  35,  375 

Microcytes,  512 

Miliary  tuberculosis,  591 

Mineral  springs,  315  ;  substances  of  food, 
42 

Mitosis  in  gastric  tumors,  563 

Monobutyrin,  60 

Morgagni,  columns  of,  41 

Mosquera  beef  meal,  201—203 

Motor   function    (see    Peristalsis)  ;   insuffi- 
ciency, 624 

Mouth,  nose,  pharynx,  and  larynx,  effects 
of  diseases  of,  on  the  stomach,  387 

Mucigen,  35 

Mucin,  64 

Mucosa:  structure  of  gastric,  21-3I;  intes- 
tinal, 32-38,  40;  fragments  of, 
in  wash- water  and  vomit,  137- 
140 ;  diagnostic  significance  of 
exfoliaiions  and  erosions,  141  ; 
conductivity  with  reference  to 
electricity,  83-86,  306,  307 

Mucous  membrane  (see  Mucosa) 

Mucus,  21,  23,  25,  133 

Muscular  coat  of  stomach,  20,  28  ;  of  in- 
testine, 32 

Muscularis  mucosae,  22,  32,  35 

Myasthenia,  gastric  (see  Atony,  Gastric) 

Myoma,  609 

Myxoma,  613  , 

59 


N. 

Neoplasms :    benign    tumors,  606  ;  granu- 
lomatous      infections,     590 ; 
malignant  tumors,  527 
Nephritis  (see  Kidney,  Diseases) 
Nephroptosis  (see  Kidneys,  Dislocation  01 

the) 
Nerves  of  the  stomach,  31  ;  intestine,  32, 

34,  38 
Nervous   diseases  and  the   stomach,  385  ; 
eructation,  75 1;   system  and  dis- 
eases of  the  stomach,  377  ;   vom- 
iting, 754 
Nessler's  reagent,  164 
Neurasthenia     gastrica    (see     Dyspepsia, 

Nervous) 
Neuroses:   gastric,  classification  of,   731  ; 
dietetics  of,  209,  251  ;   general 
consideration    of,    732  et  seq.: 
motor,    737;    secretory,    813; 
sensory,  791 
Nitrogen,  41,  41 1 
Nutrition  in  gastric  diseases,  375 


Obturator,  1 85 

Oligocythemia,  401 

Oliguria,  721 

Oppler-Boas  bacillus,  131,  132,  565 

Organic  acids,  free,  48 ;   total,  analysis  of, 

172 
Orthopedic  treatment,  309 


Palpation,  102 
Pancreas,  59 

Pancreatic   digestion,  59-61,   294;  secre- 
tion,   physiological    stimulants 
of,  62 
Pancreatin,  345 
Papain,  347 
Papayotin,  347 
Papillomata,  606 
Papoid,  347 

Parasites,  animal,  and  gastritis,  441 
Pepsin:  source  and  origin,  22,  24,  27,  28, 
174;  action,   47,   49,    174,    177; 
tests,  50,  174,  177;  nature,  177  ; 
in    the    duodenum,  69;   ultimate 
fate  of,  71  ;  bile  action  on,  63  ; 
action  of  alcohol   on   pepsin-hy- 
drochloric  acid,   292 ;   as    a    me- 
dicinal agent,  345 
Pepsinogen  (see  Proenzymes) 
Peptone  :   peptic    product,   49 ;     test,   50 ; 
tryptic    product,    61 ;    bacterial 
jiroduct,  64  ;  absorption  of,  69  ; 
in  the  stools,  72  ;  diet,  20I 
Peptones:    casein,    61 ;    elastin,    47,    61  ; 

gelatin,  47,  61 
Peptonuria,  413 


892 


LIST   OF   SUBJECTS. 


Percussion,  loi 

Peristalsis  :  influence  of  HCl,  47 ;  bile  in- 
fluence, 64 ;  comparative  im- 
portance, 73,  93  ;  tests,  74-94  ; 
function  of,  77;  phases,  80,  86, 
87,  88  ;  passive  movements,  82; 
theories  relating  to  the  move- 
ments of  the  gastric  ingesta, 
87-93  ;  study  of,  by  X-rays,  90  ; 
conclusions  concerning  physi- 
ology of,  93  ;  electrical  stimu- 
lation, 83-86 ;  intragastric  pres- 
sure, 93 ;  factor  in  the  patho- 
logical propagation  of  micro- 
organisms, 130 ;  relation  to 
digestibility  of  food  substances, 
188,  191  ;  antiperistalsis,  214, 
215  ;  influence  of  alcohol,  295  ; 
neuroses  of,  737  ;  intestinal 
peristalsis,  32 
Peristaltic  unrest,  746 
Peritonitis,  perforation,  510 
Pexine  (see  Rennin) 
Phenol,  64 

Phloroglucin,  vanillin  test,  160 
Phosphates,  48,  409 
Phosphorus,  41,  42 
Phthisis  ventriculi,  846 
Phytobezoar,  613 
Pineapple  ferments,  348 
Pneumatosis,  752 
Pneumogastric  nerves,  31 
Poikilocytosis,  402,  512 
Polypi,  606 

Proenzymes,   pepsinogen  :   source,  23,  24, 
27,     17.5  ;    con- 
version into  pep- 
sin, 27,  47,  49, 
174;  test,  175 
rennin-zymogen  :  source,  23, 
24;  conver- 
sion      into 
rennin,  47, 
176;   tests, 

51.  177 
Prolapsus  of  the  stomach  (see  Gastropto- 
sis);   colon  (see   Coloptosis); 
spleen    (see    Splenoptosis) ; 
liver  (see  Hepatoptosis) 
Propepsin    (see    Pepsinogen    under    Pro- 
enzymes) 
Propeptone,  49,  50 

Proteids  :  their  office  in  the  economy,  42  ; 
digestion,   peptic,  47,  49,  177; 
tryptic,    61  ;     proteid    and    bile 
interaction,  64  ;  intestinal  putre- 
faction,    64 ;     in    hyperacidity, 
196-200,  251,  820 
Proteolysis:  peptic,  47-51,   177;    tryptic, 
61  ;  in  hyperacidity,  196-201, 
250,  820 
Proteoses,  49 
Protoproteose,  49 
Prozymogen,  25,  26 
Ptyalin:  salivary  digestion,  44,  45,  173; 


of  the  succus  entericus,  64 ;  in- 
fluence  of   alcohol   on,   295  ;  an 
artificial  ferment,  343 
Pulmonary  diseases  and  the  stomach,  388 
Pus  in  gastric  contents,  135 
Putrefaction :    bile    action,   64 ;   products, 
etc.,  64,  70,  71  ;   economic 
relation,  65  ;  promoting  and 
inhibitory  agencies,  64,  71, 
130;    conjugate    sulphates 
and  indol,  indices  of,  334 
Pylorectomy,   355    et  seq.;  atypical,   361  ; 

partial,  361 
Pyloric    ligaments,    18,    20;  spasm,    744; 

valve,  18,  20 
Pyloroplasty,  364,  374 
Pylorospasm,  744 

Pylorus:    hypertrophic    stenosis    of,  613 ; 
symptomatology, 
618 ;     diagnosis, 
619  ;    prognosis, 
621 ;    treatment, 
621 
insufficiency  of,  768;  obstruction 
of,  656  ;  symptom- 
atology, 657 
resection  of  the,  355  ;   spasm  of 
the,  744 
Pyopneumothorax  subphrenicus,  511 


R. 

Rectum,  41 

Reflex  vomiting,  754,  757 

Regurgitation,  763 

Renal  diseases  (see  Kidney,  Diseases) 

Rennin :  source  and  derivation,  22,  24, 
176;  action,  51,  176;  action 
destroyed,  70;  test,  60,  176; 
zymogen  (see  Proenzymes) 

Resection  of  the  pylorus,  355  ;  statistics, 
371-374 

Resorcin  test,  161 

Resorption  (see  Absorption) 

Respiration  in  stomach  diseases,  377 

Rest  and  exercise,  therapy  of,  284-288  ; 
cure.  Weir  Mitchell's,  812 

Rheumatism  and  gastric  disease,  391 

Rontgen-ray  photography  of  stomach,  640  ; 
in  studying  peristalsis,  90 

Rugae,  21 

Rumination,  764 


Saliva:  detection  in  gastric  contents,  133  ; 
nature  and    action,    44,45,  173! 
influence  of  alcohol,  295 
Sarcinae,  13 1,  440 

Sarcomata,  547  ;  classification  and  etiology, 
547,     548  ;      symptomatology, 
548;     diagnosis,    553;     prog- 
nosis, 577 
Scirrhus,  gastric,  534 


LIST  OF   SUBJECTS. 


893 


Secretion  or  secretions  :  physiological  ex- 
citants of  gastric 
and  pancreatic, 
62  ;  contempora- 
neous action  of, 
68 ;  admixtures 
of,  69  ;  of  water 
by  the  stomach, 
68;  duodenal, 
69,  134 ;  in  the 
fasting  stomach, 
150;  depend- 
ence on  peristal- 
sis, 74,  93  ;  con- 
ditioning bacte- 
rial propagation, 
1 30  ;  factor  in 
digestibility  of 
foods,  188,  196  ; 
in  neoplasms, 
550,  551  ;  neu- 
roses of,  813 
Self-digestion  of  the  stomach,  487 
Semilunar  ganglion,  38 
Sensation,  neuroses  of,  791 
Sensations    of    hunger    and    of    appetite, 

anomalies  of,  803 
Serous  coat  of  intestines,  3 1 
Sigmoid  flexure,  40 
Skatol,  64 

Skin-diseases  and  digestive  troubles,  396 
Sodium,  42 
Solar  plexus,  31 

Solutions,  standard  and  normal,  154 
Spasm,  pyloric,  744 
Spectroscopic  examination,  137 
Sphincter:  anal,  42;  pyloric,  20 
Splanchnoptosis,   705 
Splenoptosis,  721 
Spray,  intragastric,  302 
Starches,  44-47,  62 
Steapsin,  60,  63 

Stenosis:     cardiac,    65 1;     etiology,    652; 
symptomatology,    653  ; 
diagnosis,  653  ;  progno 
sis,  654  ;  treatment,  654 
hyperplastic  pyloric,  445 
cicatricial  pyloric,  5 II 
hypertrophic      pyloric,       613  ; 
symptomatology,  618  ; 
diagnosis,  619;   prog- 
nosis, 621  ;   treatment, 
621 
congenital  pyloric,  659;  diagno- 
sis, 661  ;   prognosis, 
661  ;  treatment,  662; 
effects    of    various    forms    of, 
674  ;   relative  value  of 
diagnostic  factors,  659- 
669  ;  continued  super- 
secretion  in,  669 
degree    of    obstruction,    671  ; 
prognosis,  672  ;  treatment,  672- 
674  ;   diet  in,  650 
Stomach:     macroscopic    anatomy,    17-21; 


histology,  20-31  ;  location, 
size,  and  capacity — methods 
for  determining  these,  loi-i  14 ; 
contents,  examination,  116- 
140,  143  ;  acidity  in  the  healthy 
and  dyspeptic,  751  ;  influence 
of  its  diseases  upon  other  or- 
gans and  metabolism,  375  ;  in- 
fluence of  other  affections  on 
the,  385  ;  the  blood  and  urine 
in  gastric  diseases,  401  ;  gases, 
153.  405  ;  the  clinic,  415  et 
seq. ;  hour-glass,  511  ;  hemor- 
rhage from,  680 

Stomachic  remedies,  339 

Stomach-pump,    125 

Stomach-tube  and  technics  of  its  introduc- 
tion, I16-127 

Subacidity — dietetics,  191  ;   clinical,  843 

Submucosa  of  stomach,  21  ;  of  intestine, 
32 

Succus  entericus,  64,  69,  72 

Sugar,  44,  45,  62 

Sugars:  cane,  48,  60,  68  ;  grape,  60,  69; 
invert,  48,  60  ;   milk-,  68 

Sulphates,  66,  334 

Sulphur,  41,  42 

Superacidity  (see  Hyperacidity) 

Supersecretion  (see  Hypersecretion) 

Surgery,  gastric  :  historical  review^,  349  ; 
forms  of  operations,  35  2; 
fundamental  factors  in 
mortality,  resulting,  367 

Syntonin,  49,  68 

Syphilis  of  the  stomach,  596 


Telangiectatic  carcinoma,  528 

Test-meals,  123-127 

Tetanus,  380 

Tetany,  380 

Therapy  of  stomach  diseases :  dietetics, 
187 ;  lavage  and 
the  gastric  douche, 
299 ;  electricity, 
302 ;  hydrothera- 
peutic  and  ortho- 
pedic methods, 
309;  massage, 3 10  ; 
mineral  springs, 
315  ;  important 

medicinal    agents, 

329 
Titration,  154 
Tonics,  bitter,  339 

Topfer's  method  in  analysis,  165,  166 
Tormina  ventriculi  nervosa,  746 
Transillumination  (see  Diaphany) 
Trypsin,  60,  61,  69,  70,  71,  72,  73 
Tryptones,   62 
Tryptophan,  61 

Tuberculosis  of  the  stomach,  590  ;   diagno- 
sis, 594 


894 


LIST   OF   SUBJECTS. 


Tube,  stomach-,  and  technics  of  its  intro 
duction,  1 16-127 

Tumors:  benign,  606;  malignant,  527 
of  colon,  558  ;  of  gall-bladder 
558  ;  of  liver,  557  ;  of  omen 
turn,  558;  of  peritoneum,  558 
splenic,  557 

Tyrosin,  61,  64 


U. 

Ulcer   of  the   stomach  :  condition  of  the 
blood    in ,    404 
nature    of,    486 ; 
self-digestion    of 
stomach,       487  ; 
etiology,       489- 
491  ;    symptoma- 
tology, 497,  548 ; 
diagnosis,     5^7- 
512;    differential 
diagnosis,     5^7  ! 
treatment,      197, 
207,        243-245, 
512  ;   carcinoma- 
tous,    197,    506, 
560,    570  ;  syph- 
ilitic, 600  ;  tuber- 
cular, 592 
Ulcus  ventriculi,  pepticum,  rotundum,  per- 
forans,  rodens,  corrosivum  e  diges- 
tione,    486 ;     carcinomatosum    (see 
Ulcer,  Carcinomatous) 
Urea,  395,4" 

Urine :    in    gastric   diseases,  407 ;   acidity 
in  the  healthy  and  dyspeptic,  816 


V. 

Vagus  nerve,  62 

Valvulse  conniventes,  33 

Vasa  brevia,  30 

Vermiform  appendix,  40 

Vertigo,  gastric,  378  ;   intestinal,  379 

Vigoral,  202 

Villi,  33,  34 

Viscera,  reversal  of  their  location,  720 

Vomiting  :    cerebral,   central,  spinal,  754  ; 

in  pregnancy,   758 ;    juvenile, 

759  ;    nervous  habitual,   754  ; 

neurasthenic,     hysteric,    756 ; 

periodical,   756 ;    reflex,    754, 

757 

W. 

Water  :  in  the  animal  economy,  42  ;  secre- 
tion and  absorption  in  the  stomach, 
68 

Waters:  natural  mineral,  virtues  of,  315  ; 
alkaline,  317,  320  ;  alkaline  sul- 
phur, 320  ;  chalybeate,  327,  328  ; 
acidulous,  329  ;  saline,  321,  322  ; 
sodium  chlorid,  322 ;  bitter  or 
purgative,  322,  324 ;  sulphur- 
etted, 325,  326 


Yeast  fungus,  131,  440 


Zymogen  granules,  26 
Zymogens  (see  Proenzymes) 


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having  been  made  to  meet  previous  retail  discounts.  Upon  receipt  of  the  adver- 
tised price  any  book  will  be  forwarded  by  mail  or  express,  all  charges  prepaid. 


We  keep  a  large  stock  of  Miscellaneous  Books  relating  to  Medicine  and 
Allied  Sciences,  published  in  this  country  and  abroad.  Inquiries  in  regard  to 
prices,  date  of  edition,  etc.,  will  receive  prompt  attention. 


CATALOGUES  AND  CIRCULARS  SENT  FREE  UPON  APPLICATION: 

Catalogue  No.  1. — A  complete  list  of  the  titles  of  all  our  publications  on  Medicine,  Dentistry, 
Pharmacy,  and  Allied  Sciences,  with  Classified  Index. 

Catalogue  No.  3. — Pharmaceutical  Books. 

Catalogue  No.  4. — Books  on  Chemistry  and  Chemical  Technology. 

Catalogue  No.  5. — Books  for  Nurses  and  Lay  Readers. 

Catalogue  No.  6. — Books  on  Dentistry  and  Books  used  by  Dental  Students. 

Catalogue  No.  7. — Books  on  Hygiene  and  Sanitary  Science ;  Including  Water  and  Milk 
Analysis,  Microscopy,  Physical  Education,  Hospitals,  etc. 

Catalogue  No.  8. — List  of  about  300  Standard  Books  classified  by  Subjects. 

Catalogue  No.  9. — Books  on  Nervous  and  Mental  Diseases. 

Catalogue  No.  10. — Books  on  Diseases  of  the  Eye,  Refraction,  Spectacles,  etc. 

A  GerveraLl  Catalogue. — Containing  2000  titles  of  Standard  Books  on  Medicine  and  Sur- 
gery.    American  and  English. 

Special  Circulars. — Morris'  Anatomy;  Gould  and  Pyle's  Cyclopedia;  Deaver's  Surgical 
Anatomy;  Tyson's  Practice ;  Gould's  Medical  Dictionaries;  Books  on 
the  Eye ;  Books  on  Diseases  of  the  Nervous  System  ;  The  ?  Quiz- 
Compend?  Series,  Visiting  Lists,  etc.  We  can  also  furnish  sample 
pages  of  most  of  our  publications. 


P.  Blakiston's  Son  &  Co.'s  publications  may  be  had  through  the  booksellers  in  all 
the  principal  cities  of  the  United  States  and  Canada,  or  any  book  will  be  sent,  postpaid,  upon  receipt 
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THE  PRICES  OF  ALL  BOOKS  ARE  NET. 


CLASSIFIED  LIST,  WITH  PRICES, 

OF  ALL  BOOKS  PUBLISHED  BY 
P.  BLAKISTON'S  SON  &  CO.,  PHILADELPHIA. 

When  the  price  is  not  given  below,  the  book  is  out  of  print  or  about  to  be  published. 
Cloth  binding,  unless  otherwise  speciiied.     For  full  descriptions  see  following  Catalogue, 


ANATOMY. 

Ballou.     Veterinary  Anat.      Jo. 80 

Broomell.       Anatomy     and 
Histol.  of  Mouth  and  Teeth.  4.50 

Campbell.      Dissection    Out- 
lines.       .        .        -        .      .    .50 

Deaver.     Surgical  Anatomy.  24.00 

Gordinier.  Anatomy  of  Nerv- 
ous System.     Illustrated. 

Heath.    Practical.     9th  Ed. 

Holden.  Dissector.    2  Vols. 

Osteology.     8th  Ed. 

Landmarks.     4th  Ed. 

Hughes.     Dissector.    Part  I 


6. CO 
4-25 
3  0° 
5-25 
•75 
3.C0 
3.00 
3.00 
5.00 
3. CO 
4.50 


„-.„!     Part  II. 
^     '     ■     Part  III. 
Macalister's  Text-Book.     - 
McMurrich.     Embryology. 
Minot.     Embryology 
Marshall's   Phys.  &  Anatom 

ical  Diagrams.     J40.00  and  60.00 
Morris.  Text-Book  Anat.      3d 

Ed.  846  111.    Clo.,$6.oo;  Sh.,  7.00 
Potter.       Compend   of.       6th 

Ed.     133  Illustrations.  -  .80 

Wilson's  Anatomy,  nth  Ed.  5.00 

ANESTHETICS. 
Buxton.     Anesthetics.    -  1.50 

Turnbull.    4th  Ed.  -         2.50 

BACTERIOLOGY. 
Conn.      Agricultural    Bacteri- 
ology.    Illustrated. 
Bact.  in  Milk  Products. 


Emery.  Bacteriolog.  Diag.  i 
Hewlett.  Manual  of  lUus.  4 
Williams.     Student's  Manual 

of     2d  Edition,     go  Illus.        i 
Smith.     Bacteriology.      -    -     i 

BRAIN  AND  INSANITY. 
Blackburn.  Autopsies.  -  1 
Chase.     General  Paresis.  i 

Horsley.  Brain  and  Sp.  Cord.  2 
Ireland.     Mental    Affections 

of  Children.  -  -  -  4 
Lewis.  Mental  Diseases.  7 
Mann's  Psychological  Med.  3 
Rfegis.  Mental  Medicine.  -  2 
Stearns.  Mental  Dis.  Illus.  2 
Tuke.  Dictionary  of  Psycho- 
logical Medicine.  2  Vols.  10 
Wood.    Brain  and  Overwork. 


40 


1. 

4.50 

Part  I. 

3-50 

Part  II. 

3-5° 

Part  III. 

Part  I. 

4-50 

Part  II. 

-     4-50 

Part  III. 

4-50 

- 

4.50 

Chem. 


I.2S 


CHEMISTRY. 
Technol'g'l  Books.  Water  ,Milk,etc. 
Allen.     Commercial    Organic 
Analysis.     Vol.  I. 

Vol.  II. 

Vol.  II. 

Vol.  II. 

Vol.  III. 

Vol,  III. 

Vol.  III. 

Vol.  IV. 

Bailey    and    Cady. 

Analysis.  • 
Hartley.    Medical  Chemistry.  3.00 

Clinical  Chemistry.         i.oo 

Bloxam's  Text-Book.  9th  Ed. 

Bunge.  Physiologic  and  Path- 
ologic Chemistry.     -         -         3.00 

Caldwell.      Qualitative    and 

Quantitative  Analysis.        -     i.co 
Cameron.     Oils  &  Varnishes.  2.25 

Soap  and  Candles.     -     2.00 

Clowes  and  Coleman.  Quan- 
titative Analysis.     5th  Ed.  -  3.50 

Coblentz.  Volumetric  Anal.  1.25 
Congdon.  Laboratory.  -  1.00 
Gardner.  Brewing,  etc.  -  1.50 
Gray.  Physics.  Vol.  I.  -  4.50 
Groves  and  Thorp.  Chemi- 
cal Technology.  Vol.  I.  Fuels  5.00 

Vol.  II.     Lighting.      -     4.00 

Vol.  III.  Gas  Lighting.  3  50 

Vol.  IV.  Elec.  Lighting.  3.50 

Heusler.     The  Terpencs.  4,00 


Holland,  Urine,  Gastric  Con- 
tents, Poisons  and  Milk  Anal- 
ysis.    6th  Ed.      -        -        -  Ji.oo 

Leffmann's  Medical  Chem.        .80 

Food  Analysis.      -      -      2.50 

Milk  Analysis.     -      -      1.25 

Water  Analysis.       -         1.25 

Structural  Formulae.        i.oo 

Muter.     Pract.  and  Anal.  1.25 

Oettel.     Electro-Chem.  -     .75 

Electro-Chem.  Exper.-      .75 

Richter's  Inorganic.  5th  Ed.  1.75 
Organic.  3d  Ed.  2  Vols. 

Vol.  I.  Aliphatic  Series.    3.00 
Vol. 11  Carbocyclic  "        3.C0 
Rockwood.     Chemical  Anal.  1.50 
Smith. Electro-Chem.  Anal.      1.25 
Smith  and  Keller.     Experi- 
ments.    4th  Ed.     Illus.  .60 
Sutton.     VolumetricAnal.        5.00 
Symonds.     Manual  of.              2.00 
Traube.  Physico-Chem.Meth.  1.50 
Thresh.     Water  Supplies.    -    2.00 
Ulzer  and  Fraenkel.    Tech- 
nical Chemical  Analysis.          1.25 
Woody.  Essentials  of  4th  Ed.  1.50 

CHILDREN. 
Hatfield.  Compend  of  3d  Ed.   .80 
Power.    Surgical  Diseases  of.  2.50 
Smith.    Wasting  Diseases  of.    2.00 
Starr.    Digestive  Organs  of.       3.00 

Hygiene  of  the  Nursery.i.oo 

Taylor  and 'Wells.  Manual.  4.50 

CLINICAL  CHARTS,  ETC. 
Griffith's     Temp't're  Charts. 

Pads  of  50   -      .   .  -  .50 

Keen.     Outline    Drawings    of 

Human  Body.     Pads.    -  .25 

Schreiner.   Diet  Lists.    Pads,   .75 

COMPENDS. 

Ballou.     Veterinary  Anat.  .80 

Brubaker's  Physiol,  nth  Ed.  .80 

Cushing.     Histology.     -     -  .80 

Gould  and  Pyle.     The  Eye.  .80 

Hatfield.     Children.     3d  Ed.  .80 

Horwitz.     Surgery.     5th  Ed.  .80 

Hughes.  Practice.  2  Pts.  Ea.  .80 

Kyle.     Ear,  Nose,  Throat.       

Landis.    Obstetrics.    7th  Ed.  .80 

Leffmann's  Chemistry.  4th  Ed.  .80 

Potter's    Anatomy,   6th  Ed.  .80 

Materia  Medica.  6th  Ed.  .80 

Schamberg.     Skin  Diseases.  .80 

Stewart.  Pharmacy.  5th  Ed.  .80 

Thayer.     General  Pathology.  .80 

Special  Pathology.  .80 

Warren.     Dentistry.    3d  Ed  .?o 

Wells.     Gynecology.    2d  Ed.  .80 

A7iy  of  above,  Interleaved,  $1.00. 
Self-  Examination.         3500 
Questions   on   Medical    Sub- 
jects. -  -  Paper,    .10 

CONSUMPTION. 
Knopf.  Pulraon.T>iberculosis.  3.00 
Steell.    Physical  Signs  of  Pul- 
monary Disease.      -      .      -     1.25 

DENTISTRY. 
Barrett.     Dental  Surg.    -  i.oo 

Broomell.    Anat.  and  Hist,  of 

Mouth  and  Teeth.  -  -  4.50 
Fillebrown.  Op.  Dent.  Illus.  2.25 
Gorgas.     Dental  Medicine.      4.00 

Questions  and  Answers.  6.00 

Harris.     Principles  and  Prac.  6.00 

Dictionary  of.     6th  Ed.  5.00 

Richardson.  Mech.  Dent.  5.00 
Smith.  Dental  Metallurgy.  2.00 
Taft.  Index  of  Dental  Lit.  2.00 
Tomes.     Dental  Surgery.  4.00 

■  Dental  Anatomy.  4.00 

W^arren's  Compend  of.     -  .80 

Dental    Prosthesis   and 

Metallurgy.      Illus.        -  1.25 

White.    Mouth  and  Teeth.         .40 


DIAGNOSIS. 
Brown.     Medical.     4th  Ed.   ^1.25 
Tyson's  Manual.  4th  Ed.  Illus.  1.50 

DICTIONARIES,  ETC. 
Gould's  Illustrated  Dictionary 
of  Medicine,  Biology,  and  Al- 
lied Sciences,  etc.     5th  Edi- 
tion.    Leather,  $10.00;   Halt 
Russia.  Thumb  Index,    -      12  00 
GouId'sStudent's  Medical  Dic- 
tionary,     nth    Ed.,  Illus.,  J^ 
Mor.,  $2.50;   Thumb  Ind.,    3.00 
Gould's    Pocket  Dictionary — 
30,000  medical  words.     4th 
Edition.  Enlarged.  Leather,  i.oo 
Gould  and  Pyle.    Cyclopedia 
of  Med.  and  Surg.     One  Vol. 
Illus.  Leather,  10.00 

Gould    and     Pyle's    Pocket 

Cyclopedia  of  Medicine.  i.oo 

Harris'  Dental.  Clo.  5.00;  Shp.  6.co 
Longley's  Pronouncing.  .75 

Maxwell.  Tcrminologia  Med- 
ica Polyglotta.  -        -        3.00 
Treves.     German-English.        3.25 

EAR. 
Burnett.     Hearing,  etc.  .40 

Hovell.     Treatise  on.  -     5.50 

Kyle.     Ear,  Nose,  Throat.      

Pritchard.  Diseasesof.  jd  Ed.  1.50 

ELECTRICITY. 
Bigelow.     Plain  Talks  on.       i.oo 
Hedley.     Therapeutic  Elec.     2.50 
Jacobi.  Electrotherapy.  2V0IS.  5.00 
Jones.     Medical  Electricity.     3.00 

EYE. 
Bonders.    Refraction.  -      1.25 

Fick.     Diseases  of  the  Eye.      4.50 
Gould  and  Pyle.   Compend.      .80 
Greeff.     Microscopic  Examin- 
ation of.    -        .         .        -         1.25 
Harlan.     Eyesight.  -  .40 

Hartridge.  Refraction,  nth  Ed.  1. 50 

Ophthalmoscope.  4th  Ed.  1.50 

Hansell  and  Sweet.     Treat- 
ise on  Diseases  of  -  

Hansell    and    Reber.     Mus- 
cular Anomalies  of  the  Eye.  1.50 
Hansell   and    Bell.    Clinical 

Ophthalniology.  120  Illus.  1.50 
Jennings.  Ophthalmoscopy.  1.50 
Morton.  Refraction.  6th  Ed.  i.oo 
Ohlemann.  Ocular  Therap.  1.75 
Parsons.  Optics.  -  -  2.00 
Phillips.  Spectacles  and  Eye- 
glasses. 49  Illus.  3d  Ed.  I.oo 
Swanzy's  Handbook.  7th  Ed.  2.50 
Thorington.     Retinoscopy.      i.oo 

Refraction.     200  Illus.  1.50 

^Valker.     Student's  Aid.  1.50 

Wright.     Ophthalmology.        3.00 

GYNECOLOGY. 
Bishop.      Uterine   Fibromyo- 

mata.     Illustrated.       -      -       3.50 
Byford  (H.  T.).     Manual.    3d 

Edition.     363  Illustrations.     3.00 
Diihrssen.     Gynecological 

Practice.     105  Illustrations.    1.50 
Lewers.     Dis.  of  Women.         2.50 

Cancer  of  Uterus.  3.00 

Montgomery.       Text -book 

of.  527  Illus.  ...  5.00 
Roberts.  Gynecological  Path- 
ology. Illustrated.  -  6.00 
\A^ells.  Compend.  Illus.  .80 
HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.  The  Skin.  -  .40 
Burnett.  Hearing.  -  .40 
Cohen.  Throat  and  Voice.  .40 
Dulles.  Emergencies.  5th  Ed.  1.00 
Harlan.  Eyesight.  -  .40 
Hartshorne.  Our  Homes.  .40 
Osgood.  Dangers  of  Winter.  .40 
Packard.  Sea  Air,  etc.  .40 
Richardson's  Long  Life.  .40 
White.  Mouth  and  Teeth.  ,40 
■Wilson.     Summer  and  its  Dis.  .40 


4 


CLASSIFIED  LIST  OF  P.  BLAKISTON'S  SON  &-  CO.'S  PUBLICATIONS 


HISTOLOGY. 
Gushing.     Compend.      -     -  Jo. 80 
Stirling.    Histology.    2d  Ed.    2.00 
Stohr's  Histology.   Illus.      -     3.00 

HYGIENE. 
Canfield.   Hygiene  of  the  Sick- 
Room.       .        -        -        -        1.25 

Coplin.     Practical  Hygiene.    

Kenwood.       Public     Health 

Laboratory  Guide.  -  2.00 

Lincoln.  School  Hygiene.  .40 
McFarland.  Prophyla.xis.  2.50 
Notter.  Practical  Hygiene.  7.00 
Parkes'  (L.  C),  Manual.  3  00 

Rosenau.     Disinfection  and 

Disinfectants.      Illus.         -      2.00 

Starr.  Hygiene  of  the  Nursery,  i.oo 

Stevenson  and  Murphy.  A 

Treatise  on  Hygiene.     In  3 

Vols.     Circular  Vol.  I,   6.00 

upon  application.      Vol.  II,   6.00 

Vol.111,   5.00 

Thresh.     Water  Supplies.        2.00 

^Vilson's  Handbook.  8th  Ed.   3.00 

V^eyl.     Coal-Tar  Colors,  1.25 

MASSAGE,  ETC. 
Mitchell  and  Gulick.      Me- 
chanotherapy.    Illustrated.    2.50 
Ostrom.   Massage.  115  Illus.   i.oo 

MATERIA  MEDICA. 
Bracken.     Materia  Med.  2.75 

Coblentz.  Newer  Remedies,  i.oo 
Gorgas.  Dental,  sth  Ed.  4.C0 
Groff.  Mat.  Med.  lor  Nurses.  1.25 
Heller.     Essentials  of.  -     1.50 

Potter's  Compend  of.  6th  Ed.  .80 
Potter's    Handbook    of.     gth 

Ed.  Cloth,  $5.00;  Sheep,  6.00 
Sayre.   Organic  Materia  Med. 

and  Pharmacognosy.  -  4.50 
Tavera.     Medicinal  Plants  of 

the  Philippines.        -        -        2.00 
White   and  Wilcox.      Mat. 
Med.,  Pharmacy,  Pharmacol- 
ogy, and  Therapeutics.    5th 
Ed.  Enlarged.  CI. ,$3. 00;  Sh.  3.50 

MEDICAL  JURISPRUDENCE. 
Mann.     Forensic  Med.        -      6.50 
Reese.  Med.  Jurisprudence  and 
Toxicology . 6th  Ed.  J3.00;  Sh.  3. 50 

MICROSCOPE. 
Carpenter.     The  Microscope. 

Sth  Ed.     850  Illus.           -        8.00 
Greenish.    Microscopical  Ex- 
am, of  Foods  and  Drugs.  -  

Lee.  Vade  Mecum  of.  5th  Ed.  4.00 
Oertel.     Med.  Microscopy.      2.00 
Reeves.  Med.  Microscopy.      2.50 
Wethered.      Medical  Micros- 
copy,    illus.        -        -         .     2.00 

MISCELLANEOUS. 
Black.     Micro-organisms.  .75 

Burnet.  Food  and  Dietaries.  1.50 
Cohen.     Organotherapy.  2.50 

Da  Costa.  Hematology.  -  5.00 
Davis.  Alimentotherapy.  2.50 
Fenwick.  Cancer  of  Stom.  3  00 
Goodall    and    Washbourn. 

Infectious  Diseases.  Illus.  3.00 
Gould.     Borderland  Studies.    2.00 

Biographic  Clinics.        i.oo 

Greene.   Medical  Examination 

in  Life  Insurance.  Iilus.  -  4.00 
Haig.     Uric  Acid.     6th  Ed.      

Diet  and  Food.  4th  Ed.   i.oo 

Hare.     Mediastinal  Disease.     2.00 
Heinmeter.  Diseases  of  Stom- 
ach.    2d  Edition.     Illus.     -    6.00 

Disea,ses  of  Intestines. 

Illustrated.     2  Vols.       -        10.00 

Henry.  Ansemia.  -  -  .50 
McCook.  Amer.  "Spiders.  40.00 
New  Sydenham  Society's 

Publications,  each  year.  -  8.00 
Scheube.     Diseases  of  Warm 

Countries.  Illustrated.  -  8  co 
Schofield.  The  Force  of  Mind.  2.00 
Thome.     Schott  Methods  in 

Heart  Disease.        -        -  2.00 

Tissier.     Pneumatotherapy.     2.50 
Treves.     Physical  Education.    .75 
Weber  and  Hinsdale.     Cli- 
mate.   2  Vols.     Illustrated.     5.00 
^Vinternitz.    Hydrotherapy.  2.50 


NERVOUS  DISEASES,  ETC. 

Dercum.  Rest,  Mental  Thera- 
peutics, Suggestion.         -        ^2.50 

Frenkel.     Tabetic  Ataxia.        3.00 

Gordinier.  Anatomy  of  Cen- 
tral Nervous  System.      -         6.00 

Gowers.  Manual  of.  530  Illus. 
Vol.  1,5400  ;  Vol.  II,      -        4.00 

Syphilis  and  the  Ner- 
vous System.       ...      i.oo 

Epilepsy.     New  Ed.       3.00 

Ormerod.  Manual  of.  -  i.oo 
Pershing.    Diagnosis  of  Nerv. 

ar.d  Mental  Diseases.  -  1.25 
Preston.     Hysteria.     Illus.      2.00 

NURSING. 

Canfield.  Hygiene  of  the  Sick- 

Room.  ....  1.25 
CufT.  Lectures  on.  3d  Ed.  1.25 
Davis.  Bandaging.  Illus.  1.50 
Domville's  Manual.  Sth  Ed.  .75 
FuUerton.     Obst.  Nursing,     i.oo 

Surgical  Nursing.  i.oo 

Gould.  Pocket  Medical  Dic- 
tionary.    Limp  Morocco.        i.oo 

Groff.  Mat.  Med.  for  Nurses.  1.25 
Hadley.  Manual  of.  -  1.25 
Humphrey.  Manual.  23d  Ed.  i.oo 
Starr.  Hygiene  of  the  Nursery,  i.oo 
Temperature  Charts.  Pads.  .50 
Voswinkel.     Surg.  Nursing,   i.oo 

OBSTETRICS. 
Cazeauxand  Tarnier.   Text- 
Book  of.     Colored  Plates.        4.50 

Edgar.     Text-book  of.  -     

Landis.  Compend.  6th  Ed.  .80 
^Vinckel's  Text-book.  5.00 

PATHOLOGY. 
Barlow.     Pathological  Anat.  6.50 
Blackburn.     Autopsies.  1.25 

Coplin.  Manual  of.  3d  Ed.  3.50 
Da  Costa.  The  Blood.  -  5.00 
MacLeod.  Pathology  of  Skin.  6.co 
Roberts.  Gynecological  Path- 
ology. Illustrated.  -  6.00 
Thayer.     General  Pathology      .So 

Special  Pathology.  .80 

Virchow.     Post-mortems.  .75 

Whitacre.    Lab.  Text-book.    1.50 

PHARMACY. 
Beasley's  Receipt-Book.      -    2.00 

Formulary.      -        -  2.00 

Coblentz.  Manual  of  Pharm.  3.50 
Proctor.  Practical  Pharm.  3.00 
Robinson.  Latin Grammarof.  1.75 
Sayre.    Organic  Materia  Med. 

and  Pharmacognosy.  2d  Ed.  4.50 
Scoville.     Compounding.  2.50 

Stewart's  Compend.  5th  Ed.  .80 
U.   S.   Pharmacopoeia.     7th 

Revision.  1890  CI. $2.50;  Sh.,  3.00 

Postage  extra,   .27 

Select  Tables  from  U.  S.  P.       .25 

PHYSIOLOGY. 

Birch.  Practical  Physiology.  1.75 
Brubaker's Compend.  nth  Ed.  .80 
Jones.     Outlines  of.      -        -      1.50 
Kirkes'  New  17th  Ed.    (Halli- 
burton.)   Cloth,  ^3. 00;   Sh.,  3.75 

Landois'  Text-book.  845  Illus. 

Starling.  Elements  of.  -  i.oo 
Stirling.  Practical  Phys.  2.00 
Tyson's  Cell  Doctrine.       -       1.50 

POISONS. 

Reese.  Toxicology.  4th  Ed.  3.00 
Tanner.     Memoranda  of.  .75 

PRACTICE. 
Beale.     Slight  Ailments.  1.25 

Fagge.     Practice.     Vol.  I,        6.00 
Vol.11,     600 
Fowler's  Dictionary  of.      -      3.00 
Gould  and  Pyle.    Cyclopedia 

of  Medicine.  Illustrated.  10.00 
Hughes.  Cornpend.  2  Pts.  ea.    .80 

Physician's  Edition. 

I  Vol.  Morocco,  Gilt  edge.     2.25 
Taylor's  Manual  of.  6th  Ed.     4.00 
Tyson.    The  Practice  of  Medi- 
cine. Illus.  CI.  fc.;o;  Sheep     6.50 


SKIN. 

Bulkley.  The  Skin.  -  ^[0.40 
Crocker.  Dis.  of  Skin.  Illus.  5.00 
MacLeod.  Pathology  of  Skin.  6.00 
Schamberg.     Compend.  .80 

Van   Harlingen.     Diagnosis 

and  Treatment  of  Skin  Dis. 

3d  Ed.     60  Illus.      -        -        2.75 


SURGERY  AND   SURGICAL 

DISEASES. 
Berry.     Thyroid  Gland.      -      4.00 
Butlin.  Surgery  of  Malignant 

Disease.  -  -        -        4.50 

Davis.     Bandaging.     Illus.       1.50 

Deaver.    Appendicitis.        -    

Surgical  Anatomy.     .  24.00 

Douglas.     Surgical   Diseases 

of  Abdomen.     Illus.      -      -    

Dulles.  Emergencies.  -  i.oo 
Hamilton.  Tumors.  3d  Ed.  1.25 
Heath's  Minor.    12th  Ed.         1.50 

Clinical  Lectures.        -    2.00 

Horwitz.  Compend.  5th  Ed.  .80 
Jacobson.  Operations  of.  -  10.00 
Keay.  Gall-Stone  Disease.  1.25 
Kehr.  Gall-StoneDisease  -  2.50 
Macready  on  Ruptures  -  6.00 
Makins.  Surgical  Experi- 
ences in  South  Africa.  -  4.00 
Maylard.  Surgery  of  the  Ali- 
mentary Canal.  -  -  3.00 
Morris.     Renal  Surgery.  2.00 

Moullin.      Complete     Text- 
book.    3d  Ed.  by  Hamilton. 
600  Illustrations.         -        -     6.00 
Smith.     Abdominal  Surg.        10.00 
Voswinkel.  Surg.  Nursing,      i.oo 
■Walsham.  Surgery.  7th  Ed.  3.50 


THERAPEUTICS. 

Beasley's  3000  Prescriptions.  2.00 
Coblentz.  New  Remedies,  i.oo 
Cohen.  Physiologic  Thera- 
peutics. II  Volumes.  27-50 
Mays.  Theine.  -  -  .50 
Murray.  Notes  on  Remedies.  1.25 
Potter's  Compend.     6th  Ed.       .80 

Handbook  of  Mat.  Med. 

Phar.  and  Thera.     9th  Ed.      5.00 
^Vhite   and    \A^ilcox.     Mat. 
Med.,  Pharmacy,  Pharmacol- 
ogy, and  Therap.     5th  Ed.     3.00 


THROAT  AND  NOSE. 

Cohen.     Throat  and  Voice.  .40 

Hall.     Nose  and  Throat.     .  2,75 

Hollopeter.     Hay  Fever.  i.oo 

Knight.     Throat.     Illus.     -    

Kyle.     Ear,  Nose,  Throat.      

McBride.      Clinical  Manual, 

Colored  Plates,     3d  Ed.     -  7.00 

Potter.     Stammering,  etc.  i.oo 


URINE  &  URINARY  ORGANS. 
Acton.     Repro.  Organs.  1.75 

Holland.  The  Urine,  Milk  and 

Common  Poisons.  6th  Ed.  i.oo 
Kleen.     Diabetes.  -        -     2.50 

Memminger.     Diagnosis   by 

tlie  Urine.  2d  Ed.  Illus.  i.oo 
Morris.     Renal  Surgery.  2.00 

Moullin.     The  Prostate.     -     1.75 

The  Bladder.         -  1.50 

Scott.      Clinical   and   Micros. 

Examination  of  Urine.  -  5.C0 
Tyson.  Exam,  of  Urine.  1.50 
Van  Nijys.    Urine  Analysis,    i.oo 

VENEREAL  DISEASES. 

Gowers.      Syphilis   and    the 

Nervous  System.  -  -  i.oo 
Sturgis.    Manual  of.    7th  Ed.  1.25 

VISITING  LISTS. 

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REVISED  EDITION. 


TYSON'S  PRACTICE 

A  TEXT-BOOK  FOR  PRACTITIONERS  AND  STUDENTS 
WITH  SPECIAL  REFERENCE  TO  DIAGNOSIS  AND  TREATMENT 

By  JAMES  TYSON,  M.D. 

Professor  of  Medicine  in  the  University  o/  Pennsylvania ;   Physician  to  the  University  and 
Philadelphia  Hospitals,  etc. 


COLORED  PLATES  AND  125  OTHER  ILLUSTRATIONS 
Octavo.     J222  Pages.    Goth,  $5.50 ;  Leather,  $6.50 ;  Half  Russia,  $7.50 


The  object  of  this  book  is — first,  to  aid  the  student  and  physician  to  recognize 
disease,  and,  second,  to  point  out  the  proper  methods  of  treatment.  To  this  end 
Diagnosis  and  Treatment  receive  special  attention,  while  pathology  and 
morbid  anatomy  have  such  consideration  as  is  demanded  by  their  importance  as  funda- 
mental conditions  of  a  thorough  understanding  of  disease.  Dr.  Tyson' s  qualifications 
for  writing  such  a  work  are  unequaled.  It  is  really  the  outcome  of  over  thirty 
years'  experience  in  teaching  and  in  private  and  hospital  practice.  As  a 
teacher  he  has,  while  devoting  himself  chiefly  to  clinical  medicine,  occupied  several 
important  chairs,  notably  those  of  General  Pathology  and  Morbid  Anatomy,  and 
Clinical  Medicine  in  the  University  of  Pennsylvania,  an  experience  that  has  necessarily 
widened  his  point  of  view  and  added  weight  to  his  judgment.  This,  the  Second, 
Edition  has  been  most  thoroughly  revised,  parts  have  been  rewritten,  new 
material  and  illustrations  have  been  added,  and  in  many  respects  it  may  be  considered 
a  new  book. 

'*  It  is  in  the  writing  and  preparation  of  a  work  of  this  character  that  Dr.  Tyson  stands  pre- 
eminent. Those  of  the  profession — and  there  are  many  at  this  time — who  have  been  fortunate  to 
have  been  his  pupils  during  their  medical  student  days,  will  remember  that  he  brought  to  his 
lectures  and  to  his  writings  an  amount  of  industry  and  care  which  many  other  teachers  failed  to 
bring ;  and  those  who  know  him  best  as  an  author  and  teacher  have  expected  that  his  book  on  the 
Practice  of  Medicine,  when  it  appeared,  would  be  a  credit  to  himself,  and  would  increase  his 
reputation  as  a  medical  author.    This  belief  has  proved  correct. ' ' —  Therapeutic  Gazette,  Detroit,  Mich. 

"  After  a  third  of  a  century  spent  in  the  assiduous  study,  practice,  and  teaching  of  medicine, 
and  the  publication  of  successful  books  on  various  topics,  theoretical  and  practical,  the  writing  of  a 
text-book  is  not  only  a  proper  ambition,  but  is  really  expected  by  students  and  the  profession.  So 
Professor  Tyson  best  shows  his  modesty  by  making  no  apology  for  the  present  work." — American 
Journal  of  Medical  Sciences,  Philadelphia. 

4 


fi^'All  prices  are  net.    No  discount  can  be  allowed  retail  purchasers. 


P.  BLAKISTON'S  SON  &  CO.'S 

Medical  and  Scientific  Publications. 


Acton.     The  Functions  and   Disorders  of  the  Reproductive  Organs 

in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life,  considered  in  their  Physiological, 
Social,  and  Moral  Relations.   By  Wm.  Acton,  m.d.,  m.r.c.s.   8th  Edition.  Cloth,  $1.75 

Allen.     Commercial  Organic  Analysis. 

New  Revised  Editions.  A  Treatise  on  the  Properties,  Proximate  Analytical  Exami- 
nation and  Modes  of  Assaying  the  Various  Organic  Chemicals  and  Products  employed 
in  the  Arts,  Manufactures,  Medicine,  etc.,  with  Concise  Methods  for  the  Detection 
and  Determination  of  Impurities,  Adulterations,  and  Products  of  Decomposition,  etc. 
Revised  and  Enlarged.  By  Alfred  H.  Allen,  f.c.s.,  Pubhc  Analyst  for  the  West 
Riding  of  Yorkshire  ;  Past  President  Society  of  Public  Analysts  of  Great  Britain. 

Vol.  I.  Preliminary  Examination  of  Organic  Bodies.  Alcohols,  Neutral  Alcoholic 
Derivatives,  Ethers,  Starch  and  its  Isomers,  Sugars,  Acid  Derivatives  of  Alcohols 
and  Vegetable  Acids,  etc.  Third  Edition,  with  numerous  additions  yb  the 
author,  and  revisions  and  additions  by  Dr.  Henry  Leffmann,  Professor  of 
Chemistry  and  Metallurgy  in  the  Pennsylvania  College  of  Dental  Surgery,  and 
in  the  Wagner  Free  Institute  of  Science,  Philadelphia,  etc.  With  many  useful 
tables.  Cloth,  $4- 5° 

Vol.  II — Part  I.  Fixed  Oils,  Fats,  Waxes,  Glycerin,  Soaps,  Nitroglycerin, 
Dynamite  and  Smokeless  Powders,  Wool-Fats,  Degras,  etc.  Third  Edition, 
with  many  useful  tables.  Revised  by  Dr.  Henry  Leffmann,  with  numerous 
additions  by  the  author.  Cloth,  I3.50 

Vol.  II — Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants,  Asphalt,  Benzene  and 
Naphthalene,  Phenols,  Creosote,  etc.  Third  Edition,  Revised  by  Dr.  Henry 
Leffmann,  with  additions  by  the  author.  Cloth,  $3.50 

Vol.  II — Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors,  Aromatic  Acids, 
etc.     Third  Edition.  In  Preparation. 

Vol.  Ill — Part  I.  Tannins,  Dyes,  Coloring  Matters,  and  Writing  Inks.  Third 
Edition,  Revised,  Rewritten,  and  Enlarged  by  I.  Merritt  Matthews,  Professor 
of  Chemistry  and  Dyeing  at  the  Philadelphia  Textile  School  ;  Member  American 
Chemical  Society.  Cloth,  $4.50 

Vol.  Ill — Part  II.  The  Amines  and  Ammonium  Bases,  Hydrazines  and  Deriva- 
tives. Bases  from  Tar.  The  Antipyretics,  etc.  Vegetable  Alkaloids,  Tea, 
Coffee,  Cocoa,  Kola,  Cocaine,  Opium,  etc.     Second  Edition.     8vo.    Cloth,  $4.50 

Vol.  Ill — Part  III.  Vegetable  Alkaloids  concluded,  Non-Basic  Vegetable  Bitter 
Principles.  Animal  Bases,  Animal  Acids,  Cyanogen  and  its  Derivatives,  etc. 
Second  Edition.  Cloth,  $4.50 

Vol.  IV.  Proteids  and  Albuminous  Principles.  Proteoids  or  Albuminoids. 
Second  Edition,  with  elaborate  appendices  and  a  large  number  of  useful  tables. 

Cloth,  I4. 50 

Bailey  and  Cady.     Chemical  Analysis. 

Laboratory  Guide  to  the  Study  of  Qualitative  Analysis.  By  E.  H.  S.  Bailey,  Ph.D., 
Professor  of  Chemistry,  and  Hamilton  Cady,  a.b..  Assistant  Professor  of  Chemistry 
in  the  University  of  Kansas.      Fourth  Edition.  Cloth,  j?i.2  5 

3-23-03-  ■  .5 


p.  BLAKISTON'S  SON  &-   CO.'S 


Ballou.     Veterinary  Anatomy  and  Physiology. 

By  Wm.  R.  Ballou,  m.d.,  late  Professor  of  Equine  Anatomy,  New  York  College  of 
Veterinary  Surgeons.  With  29  Graphic  Illustrations.  i2mo.  No.  12  ?Quiz-Com- 
pendf  Series.  Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  $1.00 

Barrett.     Dental  Surgery 

for  General  Practitioners  and  Students  of  Medicine  and  Dentistry.  Extraction  of 
Teeth,  etc.     By  A.  W.  Barrett,  m.d.     Third  Ed.     86  lUus.      i2mo.     Cloth,  |i. 00 

Hartley.     Medical  and  Pharmaceutical  Chemistry. 

A  Text-Book  for  Medical  and  Pharmaceutical  Students.  By  E.  H.  Bartley,  m.d., 
Professor  of  Chemistry  and  Toxicology  at  the  Long  Island  College  Hospital  ;  Dean 
and  Professor  of  Chemistry,  Brooklyn  College  of  Pharmacy  ;  Chief  Chemist,  Board 
of  Health  of  Brooklyn,  N.  Y.  Fifth  Edition,  Revised  and  Improved.  With  Illus- 
trations, Glossary,  and  Complete  Index.      i2mo.  Cloth,  $3.00;  Leather,  $3.50 

"  The  subject-matter  is  excellent.  The  descriptions  are  detailed  and  very  complete.  All  of 
these  properties  make  the  book  an  excellent  one  for  a  book  of  reference.  Indeed,  if  the  book  be 
considered  in  the  light  of  this  purpose,  it  is  hard  to  find  anything  in  it  for  adverse  criticism." — 
Boston  Medical  and  Stirgica I  Journal. 

Clinical  Chemistry. 

The  Chemical  Examination  of  the  Saliva,  Gastric  Juice,  Feces,  Milk,  LMne,  etc., 
with  Notes  on  Urinary  Diagnosis,  Volumetric  Analysis,  and  Weights  and  Meas- 
ures.    Illustrated.      i2mo.  Cloth,  $1.00 

Beale.     On  Slight  Ailments. 

Their  Nature  and  Treatment.  By  Lionel  S.  Beale,  m.d.,  f.r.s..  Professor  of 
Practice,  King's  Medical  College,  London.     Second  Edition.     Bvo.  Cloth,  $1.25 

Beasley's  Book  of  Prescriptions. 

Containing  over  3100  Prescriptions,  collected  from  the  Practice  of  the  most  Eminent 
Physicians  and  Surgeons — English,  French,  and  American  ;  a  Compendious  History 
of  the  Materia  Medica,  Lists  of  the  Doses  of  all  Officinal  and  Established  Prepa- 
rations, and  an  Index  of  Diseases  and  their  Remedies.  By  Henry  Beasley. 
Seventh  Edition.  Cloth,  $2.00 

Druggists'  General  Receipt  Book. 

Comprising  a  copious  Veterinary  Formulary  ;  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics  ;  Beverages, 
Dietetic  Articles,  and  Condiments  ;  Trade  Chemicals,  Scientific  Processes,  and 
an  Appendix  of  Useful  Tables.     Tenth  Edition.  Cloth,  $2.00 

Pharmaceutical  Formulary 

and  Synopsis  of  the  British,  French,  German,  and  United  States  Pharmacopoeias. 
Comprising  Standard  and  Approved  Formulae  for  the  Preparations  and  Com- 
pounds Employed  in  Medical  Practice.     Twelfth  Edition.  Cloth,  $2.00 

Berry.     The  Thyroid  Gland. 

The  Diseases  of  the  Thyroid  Gland  and  Their  Surgical  Treatment.  By  James 
Berry,  m.b.,  b.s.,  f.r.c.s.,  Surgeon  to  the  Royal  Free  Hospital.  121  Illustrations, 
from  Original  Photographs  of  Cases.  Cloth,  $4.00 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS. 


Bigelow.     Plain  Talks  on  Medical  Electricity  and  Batteries. 

With  a  Therapeutic  Index  and  a  Glossary.  By  Horatio  R.  Bigelow,  m.d.  With 
43  Illustrations  and  a  Glossary.     Second  Edition.  Cloth,  ^i.oo 

Birch.     Practical  Physiology. 

An  Elementary  Class-Book.  Including  Histology,  Chemical  and  Experimental 
Physiology.  By  De  Burgh  Birch,  m.d.,  cm.,  f.r.s.e..  Professor  of  Physiology  in 
the  Yorkshire  College  of  the  Victoria  University,  etc.     62  lUus.     i2mo.    Cloth,  $1.75 

Bishop.      Uterine  Fibromyomata. 

Their  Pathology,  Diagnosis,  and  Treatment.  By  E.  Stanmore  Bishop,  f.r.c.s. 
(Eng.),  President  Manchester  Clinical  Society  ;  Fellow  British  Gynecological  Society. 
Full-page  Plates  and  other  Illustrations.     Octavo.  Cloth,  $3.50 

Black.     Micro-Organisms. 

The  Formation  of  Poisons.  A  Biological  Study  of  the  Germ  Theory  of  Disease. 
By  G.  V.  Black,  m.d.,  d.d.s.  Cloth,  .75 

Blackburn.     Autopsies.     Illustrated. 

A  Manual  of  Autopsies,  Designed  for  the  Use  of  Hospitals  for  the  Insane  and  other 
Pubhc  Institutions.  By  I.  W.  Blackburn,  m.d.,  Pathologist  to  the  Government 
Hospital  for  the  Insane.      Illustrated.  Cloth,  $1.25 

Bloxam.     Chemistry  (Inorganic  and  Organic). 

With  Experiments.  By  Charles  L.  Bloxam.  Late  Professor  of  Chemistry,  King's 
College,  London,  and  inlhe  Department  of  Artillery  Studies,  Woolwich,  England. 
Edited  by  J.  M.  Thompson,  Professor  of  Chemistry  in  King's  College,  London,  and 
A.  G.  Bloxam,  Head  of  the  Chemistry  Department,  Goldsmith's  Institute,  London. 
Ninth  Edition,  Revised  and  Enlarged.      281  Engravings.     8vo.  Preparing. 

Bracken.     Outlines  of  Materia  Medica  and  Pharmacology. 

By  H.  M.  Bracken,  Professor  of  Materia  Medica  and  Therapeutics  and  of  CHnical 
Medicine,  University  of  Minnesota.      Svo.  Cloth,  $2.75 

Broomell.     Anatomy  and   Histology  of  the  Mouth  and  Teeth. 

By  Dr.  I.  N.  Broomell,  Professor  of  Dental  Anatomy,  Dental  Histology,  and  Pros- 
thetic Technics  in  the  Pennsylvania  College  of  Dental  Surgery.  Second  Edition, 
Revised  and  Enlarged  by  72  pages.  337  handsome  Illustrations,  the  majority  of 
which  are  original.     Large  Octavo.  Cloth,  $4.50;  Leather,  $5.50 

Brown.      Medical  Diagnosis.     Fourth  Edition. 
A  Manual  of  Chnical  Methods.     By  J.  J.  Graham  Brown,  m.d.,  f.r.c.p..  Lecturer 
on   Principles  and   Practice   of  Medicine  in  the  School  of  Medicine  of  the   Royal 
Colleges,  Edinburgh.     Fourth  Edition.      112  Illustrations.      i2mo.  Cloth,  $2.25 

Brubaker.     Compend  of  Physiology.     Eleventh  Edition. 

A  Compend  of  Physiology,  specially  adapted  for  the  use  of  Students  and  Physicians. 
By  A.  P.  Brubaker,  m.d..  Adjunct  Professor  of  Physiology  at  Jefferson  Medical 
College  ;  Professor  of  Physiology,  Pennsylvania  College  of  Dental  Surgeiy,  Philadel- 
phia. Eleventh  Edition,  Revised,  Enlarged,  and  Illustrated.  No.  4  ?  Quiz- Compend? 
Series.      i2mo.  Cloth,  .80;  Interleaved,  ^i.oo 

Bulkley.     The  Skin  in  Health  and  Disease. 

By  L.  Duncan  Bulkley,  M.D.     Illustrated.  Cloth.  .40 

Bunge.     Physiologic  and  Pathologic  Chemistry. 

By  Dr.  C.  Bunge,  Professor  at  Basel.  Authorized  Translation  from  the  Fourth 
German  Edition.  Edited  by  E.  A.  Starling,  m.d.,  f.r.s..  Professor  of  Physiology 
in  University  College,  London.     Octavo.  Cloth,  $3.00 


p.  BLAKISTON'S  SON  &-    CO.' S 


Burnet.     Foods  and  Dietaries. 
A  Manual  of  Clinical  Dietetics.     By  R.  W.  Burnet,   m.d.,  m.r.c.p.,   Physician  to 
the  Great  Northern  Central  Hospital.     With  Appendix  on  Predigested  Foods  and 
Invalid  Cookery.     Full  Directions  as  to  Hours  of  Taking  Nourishment,   Quantity, 
etc.     Third  Edition.  Cloth,  51.50 

Burnett.     Hearing  and  How  to  Keep  It. 
By  Chas.  H.  Burnett,  m.d..   Professor  of  Diseases  of  the  Ear  at  the  Philadelphia 
Polyclinic.     Illustrated.  Cloth,  .40 

Butlin.  The  Operative  Surgery  of  Malignant  Disease. 
By  Henry  T.  Butlin,  f.r.c.s.,  Assistant  Surgeon  to,  and  Demonstrator  of  Surgery 
at,  St.  Bartholomew's  Hospital,  London,  etc.,  assisted  by  James  Berry,  f.r.c.s., 
Wm.  Bruce-Clarke,  m.b.,  f.r.c.s.,  A.  H.  G.  Doran,  f.r.c.s.,  Percy  Furnivall, 
F.R.C.S.,  W.  H.  H.  Jessop,  M.B.,  f.r.c.s.,  and  H.  J.  Waring,  b.Sc,  f.r.c.s. 
Second  Edition,  Revised  and  Rewritten.     Illustrated.     Octavo.  Cloth,  $4.50 

Buxton.     On  Anesthetics. 
A  Manual.     By  Dudley  Wilmot  Buxton,  m.r.c.s.,  m.r.c.p.,  Assistant  to  Professor 
of  Medicine  and  Administrator  of  Anesthetics,  University  College  Hospital,  London. 
Third  Edition,  Illustrated.      i2mo.  Cloth,  $1.50 

Byford.     Manual  of  Gynecology.     2^3  Illustrations. 

By  Henry  T.  Byford,  m.d..  Professor  of  Gynecology  and  Clinical  Gynecology  in 
the  College  of  Physicians  and  Surgeons  of  Chicago,  and  in  Post-Graduate  Medical 
School,  etc.  Third  Edition,  Revised  and  Enlarged.  363  Illustrations,  many  of  which 
are  from  original  drawings  and  several  of  which  are  Colored.      i2mo. 

Cloth,  $3.00;  Sheep,  $3.50 

Caldwell.     Chemical  Analysis. 

Elements  of  Quahtative  and  Quantitative  Chemical  Analysis.  By  G.  C.  Caldwell, 
B.S.,  Ph.D.,  Professor  of  Agricultural  and  Analytical  Chemistry  in  Cornell  Univer- 
sity, Ithaca,  New  York,  etc.     Third  Edition.     Octavo.  Cloth,  $1.00 

Cameron.     Oils  and  Varnishes. 

By  James  Cameron,  F.I. c.    Illustrations,  Formulae,  Tables,  etc.     i2mo.     Cloth,  $2.25 

Soap  and  Candles. 

A  Handbook  for  Manufacturers,  Chemists,  etc.  54  Illustrations.    i2mo.  Cloth,  $2.00 

Campbell.     Dissection  Outline  and  Index. 

A  Systematic  Outline  for  Students  for  the  Dissection  of  the  Human  Body  and  an 
Arranged  Index  adapted  for  Use  with  Morris'  Anatomy.  By  William  A.  Campbell, 
B.S.,  M.D.,  formerly  Demonstrator  of  Anatomy  in  the  Medical  Department  of  the 
University  of  Michigan,  Ann  Arbor.     Second  Edition,  Revised.  Cloth,  .50 

Canfield.     Hygiene  of  the  Sick-Room. 

Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Disinfection,  Bacteriology,  Immu- 
nity, Heating  and  Ventilation,  and  kindred  subjects,  for  the  Use  of  Nurses  and  other 
Intelligent  Women.  By  William  Buckingham  Canfield,  a.m.,  m.d.,  late  Lecturer 
on  Clinical  Medicine,  University  of  Maryland.      i2mo.  Cloth,  $1.25 

Carpenter.     The  Microscope  and  Its  Revelations. 

By  W.  B.  Carpenter,  m.d.,  f.r.s.  Eighth  Edition,  by  Rev.  Dr.  Dallinger, 
F.R.S.  Rewritten,  Revised,  and  Enlarged.  817  Illustrations  and  23  Plates.  Octavo. 
II 36  pages.  Cloth,  sS.oo  ;   Half  Morocco,  $9.00 

Chase.     General  Paresis,  Practical  and  Clinical. 

By  Robert  H.  Chase,  m.d.,  Physician-in-chief  Friends'  Asylum  for  the  Insane,  Frank- 
ford,  Philadelphia  ;  late  Resident  Physician  State  Hospital  for  Insane,  Norristown, 
Pennsylvania,  etc.     Illustrated.     Just  Ready.  Cloth,  $1.75 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS. 


Cazeaux  and  Tarnier's  Midwifery.     With  Appendix,  by  Munde. 

The  Theory  and  Practice  of  Obstetrics,  including  the  Diseases  of  Pregnancy  and 
Parturition,  Obstetrical  Operations,  etc.  By  P.  Cazeaux.  Remodeled,  rearranged, 
and  revised  by  S.  Tarnier,  m.d.  Eighth  American  from  the  Eighth  French  and 
First  ItaHan  Edition.  Edited  by  Robert  J.  Hess,  ji.d.  With  an  Appendix  by  Paul 
F.  MUXDE,  M.D.  Illustrated  by  Lithographs,  Full-page  Plates,  and  numerous  En- 
gravings.    8vo.  Cloth,  $4.50;  Full  Leather,  $5.50 

Clowes  and  Coleman.     Quantitative  Analysis. 
Adapted  for  the  Use  of  the  Laboratories  of  Schools  and  Colleges.     By  Frank  Clowes, 
Sc.D.,   Emeritus   Professor    of   Chemistry,    University    College,   Nottingham,   and    L 
Bernard  Coleman,  Assoc.  R.  C.  Sci.,  Dubhn,   Professor  of  Chemistry,   Southwest 
London  Polytechnic.     Fifth  Edition.      122  Illustrations.  Cloth,  $3.50 

Coblentz.     Manual  of  Pharmacy. 
A  Text-Book  for  Students.     By  Virgil  Coblentz,  a.m.,  ph.d.,  f.c.s..  Professor  of 
Chemistr>^  and  Physics  ;  Director  of  Pharmaceutical  Laborator>s    College  of  Phar- 
macy of  the  City  of  New  York.     Second  Edition,  Revised  and  Enlarged.     437  Illus- 
trations.    Octavo.     572  pages.  Cloth,  $3.50  ;  Sheep,  I4. 50 

The  Newer  Remedies. 

Including  their  Synonyms,  Sources,  ]\Iethods  of  Preparation,  Tests,  Solubilities, 
and  Doses  as  far  as  known.  Together  with  Sections  on  Organo-Therapeutic 
Agents  and  Indifferent  Compounds  of  Iron.  Third  Edition,  very  much  enlarged. 
Octavo.  Cloth,  $1.00 

Volumetric  Analysis. 

A  Practical  Handbook  for  Students  of  Chemistry.  Including  Indicators,  Test- 
Papers,  Alkalimetr>',  Acidimetry,  Analysis  by  Oxidation  and  Reduction,  lodom- 
etry.  Assay  Processes  for  Drugs  with  the  Titrimetric  Estimation  of  Alkaloids, 
Estimation  of  Phenol,  Sugar,  Tables  of  Atomic  and  Molecular  Weights. 
Illustrated.      8vo.  Cloth,  $1.25 

Cohen.     System  of  Physiologic  Therapeutics.     Illustrated. 

A  Practical  Exposition  of  the  Methods  Other  than  Drug-giving,  Useful  in  the  Treat- 
ment of  the  Sick  and  in  the  Prevention  of  Disease,  i-dited  by  Solomon  Solis 
Cohen,  A.M.,  m.d..  Senior  Assistant  Professor  of  Clinical  Medicine  at  Jefferson 
Medical  College  ;  formerly  Professor  of  Medicine  and  Therapeutics  in  the  Phila- 
delphia Polyclinic  ;  Physician  to  the  Philadelphia  and  Jewish  Hospitals  and  to  the 
Rush  Hospital  for  Consumption  ;  formerly  Lecturer  on  Therapeutics,  Dartmouth 
Medical  College.     To  be  issued  in   Eleven  Compact  Octavo  Volumes. 

By  Subscription  only.     Complete  Set,  Cloth,  $27.50;  Half  Morocco,  $38.50 

Electrotherapy.  220  Illustrations.  Two  Volumes.  Ready. 
By  George  W.  Jacoby,  m.d.,  New  York,  Consulting  Neurologist  to  the  German 
Hospital,  to  the  Infirmar>'  for  Women  and  Children,  to  the  Craig  Colony  for 
Epileptics,  etc.  Special  articles  by  Edward  Jackson,  a.m.,  m.d.,  Denver, 
Col. ;  Emeritus  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polychnic  ; 
Member  American  Ophthalmological  Society  ;  Fellow  and  ex-President  American 
Academy  of  Medicine,  etc. — By  William  Scheppegrell,  m.d..  New  Orleans, 
ex-Vice-'President  American  Larjmgological,  Rhinological,  and  Otological 
Society. — By  J.  Chalmers  Da  Costa,  m.d.,  Chnical  Professor  of  Surgery  in 
Jefferson  Medical  College;  Surgeon  to  the  Philadelphia  and  to  St.  Joseph's 
Hospitals,  etc. — By  Franklin  H.  Martin,  m.d..  Professor  of  Gynecology,  Post- 
Graduate  Medical  School  of  Chicago  ;  Gynecologist  Chicago  Charity  Hospital ; 
Chairman  Section  of  Obstetrics  and  Diseases  of  Women  of  the  American  Medi- 
cal Association  (1895),  etc. — By  A.  H.  Ohmann-Dumesnil,  m.d..  Editor  5/. 
Louis  Medical  ajid  Surgical  Joicrnal ;  Member  International  Dermatological 
Congress  ;  formerly  Professor  of  Dermatology,  St.  Louis  Medical  College,  etc. 


10  p.  BLAKISTON'S  SON  &-   CO.'S 

Cohen.     Physiologic  Therapeutics. — Continued. 

Climatology   and   Health   Resorts,    Including   Mineral    Springs. 
Two  Volumes,  with  Colored  Maps.     Ready. 

By  F.  Parkes  Weber,  m.a.,  m.d.,  f.r.c.p.  (Lond.),  Physician  to  the  German 
Hospital,  Dalston  ;  Assistant  Physician  North  London  Hospital  for  Consump- 
tion ;  Author  of  "The  Mineral  Waters  and  Health  Resorts  of  Europe  ;"  and 
Guy  Hinsdale,  a.m.,  m.d..  Secretary  of  the  American  Climatological  Associa- 
tion ;  President  of  the  Pennsylvania  Society  for  the  Prevention  of  Tuberculosis, 
etc.  Including  an  article  on  Hawaii  by  TiTUS  Munson  Coan,  m.d.,  of  New- 
York.  With  Colored  Maps,  prepared  by  Dr.  W.  F.  R.  Phillips,  of  the  U.  S. 
Weather  Bureau,  Washington,  D.  C. 

Prophylaxis — Personal    Hygiene — Civic   Hygiene — Care  of  the 
Sick.     Illustrated.     Ready. 

By  Dr.  Joseph  McFarland,  Professor  of  Pathology,  Medico-Chirurgical  College, 
Philadelphia  ;  Dr.  Henry  Leffmann,  Professor  of  Chemistry  in  the  Woman's 
Medical  College,  Philadelphia;  Albert  Abrams,  a.m.,  m.d.  (University  of 
Heidelberg),  formerly  Professor  of  Pathology,  Cooper  Medical  College,  San 
Francisco  ;  and  Dr.  W.  Wayne  Babcock,  Lecturer  on  Pathology  and  Bac- 
teriology, Medico-Chirurgical  College,  Philadelphia. 

Dietotherapy  :   Food  in  Health  and  Disease.     Ready. 

By  Nathan  S.  Davis,  Jr.,  a.m.,  m.d..  Professor  of  Principles  and  Practice  of 
Medicine  in  Northwestern  University  Medical  School  ;  Physician  to  Mercy  Hos- 
pital, Chicago  ;  Member  American  Academy  of  Medicine,  American  Climato- 
logical Society,   etc.     With  Tables  of  Dietaries,   Relative  Value  of  Foods,  etc. 

Mechanotherapy  and  Physical  Education.  Illustrated. 
By  John  Kearsley  Mitchell,  m^d..  Assistant  Physician  to  the  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases  ;  Assistant  Neurologist  Presbyterian 
Hospital,  Philadelphia,  etc. ,  formerly  Lecturer  on  Symptomology  at  the  Univer- 
sity of  Pennsylvania;  and  Luther  Gulick,  m.d.,  of  Brooklyn,  N.  Y.,  formerly 
of  Springfield,  Mass.,  Mem.  American  Association  for  Advancement  of  Physical 
Education,  Amer.  Medical  Association,  etc.  With  a  Chapter  on  Orthopedic 
Appliances  by  James  K.  Young,  m.d.,  Professor  of  Orthopedic  Surgery,  Phila- 
delphia Polyclinic  ;  Instructor  in  Orthopedic  Surgery,  University  of  Pennsylvania  ; 
and  an  Article  on  Ocular  Orthopedics  by  Walter  L.  Pyle,  m.d. 

Rest — Mental  Therapeutics — Suggestion. 

By  Francis  X.  Dercum,  m.  d.,  Clinical  Professor  of  Nervous  Diseases  in  Jeffer- 
son Medical  College  ;  Neurologist  to  the  Philadelphia  Hospital  ;  Consulting 
Neurologist  to  St.  Agnes'  Hospital  ;  Neurologist  to  the  Jewish  Hospital  of  Phila- 
delphia. 

Hydrotherapy  —  Thermotherapy  —  Heliotherapy —  Crounother- 
apy — Phototherapy — Balneology.     Ready. 

By  Dr.  Wilhelm  Winternitz,  Professor  of  Clinical  Medicine  in  the  University 
of  Vienna  ;  Director  of  the  General  Polyclinic  in  Vienna,  etc. ;  assisted  by 
Dr.  Alois  Strasser,  Instructor  in  Clinical  Medicine,  University  of  Vienna  ; 
and  Dr.  B.  Buxbaum,  Chief  Physician  of  the  Hydrotherapeutic  Institute  of 
Vienna  ;  and  Dr.  E.  Heinrich  Kisch,  Professor  in  the  University  of  Prague  ; 
Physician  at  Marienbad  Spa.  With  Special  Chapters  by  Dr.  A.  C.  Peale,  of  the 
National  Museum,  Washington,  D.  C,  Dr.  J.  H.  Kellogg,  Battle  Creek, 
Mich.,  and  Harvey  Gushing,  m.d.,  Johns  Hopkins  Hospital,  Baltimore,  and 
an  Appendix  by  Dr.  Cohen. 

Pneumotherapy  and  Inhalation  Methods.     Illustrated.       Ready. 

By  Dr.  Paul  Tissier,  Chief  of  Clinic  of  the  Faculty  of  Medicine  of  Paris. 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  11 


Cohen.     Physiologic  Therapeutics. — Continued. 

Serotherapy — Organotherapy — Blood-Letting,  etc. — Principles  of 
Therapeutics — Digest — I  ndex. 

By  Joseph  McFarland,  m.d.,  Professor  of  Pathology  in  the  Medico-Chirurgical 
College,  Philadelphia  ;  Pathologist  to  the  Medico  Chirurgical  Hospital,  etc. — 
O.  T.  Osborne,  m.d..  Professor  of  Materia  Medica  and  Therapeutics,  Medical 
Department,  Yale  University,  New  Haven. — Frederick  A.  Packard,  m.d.. 
Visiting  Physician  to  the  Pennsylvania  and  to  the  Children's  Hospitals. — The 
Editor,  and  Augustus  A.  Eshner,  m.d..  Professor  of  Clinical  Medicine  in  the 
Philadelphia  Polyclinic  ;  Physician  to  the  Philadelphia  Hospital,  etc. 
*^*  Co7nphte  descriptive  circular  upon  application. 

"  There  is  surely  room  for  just  such  a  set  of  books.  We  have  been  too  prone  to  think  that  we 
were  teaching  therapeutics  sufficiently  when  we  taught  our  students  the  old  materia  medica  and  the 
use  of  mere  drugs,  forgetful  and  careless  of  the  importance  of  the  therapeutic  value  of  the  methods 
of  which  this  series  of  books  will  speak. "^/(?/^w5  Hopkins  Hospital  BuUetiji. 

Cohen.     The  Throat  and  Voice. 

By  J.  SoLis  Cohen,  m.d.     Illustrated.      i2mo.  Cloth,  .40 

Congdon.      Laboratory  Instructions  in  General  Chemistry. 

By  Ernest  A.  Congdon,  Professor  of  Chemistry  in  the  Drexel  Institute,  Philadelphia  ; 
Member  American  Chemical  Society  ;  Fellow  of  the  London  Chemical  Society,  etc. 
With  an  Appendix,  useful  Tables,  and  56  Illustrations.  Interleaved,  Cloth,  $1.00 

Conn.     Agricultural  Bacteriology. 

Including  a  Study  of  Bacteria  as  Relating  to  Agriculture,  with  Special  Reference  to 
the  Bacteria  in  Soil,  in  the  Dairy,  in  Food  Products,  in  Domestic  Animals,  and  in 
Sewage.  By  H.  W.  Conn,  Ph.D.,  Professor  of  Biology,  Wesleyan  University, 
Middletown,  Conn.;  Author  of  "Evolution  of  To-day,"  "  The  Story  of  Germ  Life," 
etc.     With  Illustrations.  Cloth.  $2. 50 

Bacteria  in  Milk  and  Its  Products. 

Designed  for  Students    of  Dairying,   Boards  of  Health,  Bacteriologists,  and  all 
concerned  in  the  Handling  of  Milk,  Butter,  and  Cheese.      Illustrated.      i2mo. 

Jicst  Ready.  Cloth,  $1.25 

Coplin.      Manual  of  Pathology.     Third  Edition.     330  Illustrations. 

Including  Bacteriology,  the  Technic  of  Post-mortems,  and  Methods  of  Pathologic 
Research.  By  W.  M.  Late  Coplin,  m.d.,  Professor  of  Pathology  and  Bacteriology, 
Jefferson  Medical  College  ;  Pathologist  to  Jefferson  Medical  College  Hospital  and  to 
the  Philadelphia  Hospital  ;  Bacteriologist  to  the  Pennsylvania  State  Board  of  Health. 
Third  Edition,  Rewritten  and  Enlarged.  330  Illustrations,  many  of  which  are  origi- 
nal, and  7  Colored  Plates.     8vo.  Cloth,  #3.50 

Practical  Plygiene. 

With  Special  Articles  on  Plumbing,  Ventilation,   etc.      138  Illustrations.     Svo. 
Second  Edition.  In  Preparation. 

Crocker.      Diseases  of  the  Skin.     Third  Edition. 

Their  Description,  Pathology,  Diagnosis,  and  Treatment,  with  Special  Reference  to 
the  Skin  Eruptions  of  Children.  By  H.  Radcliffe  Crocker,  m.d..  Physician  to 
the  Department  of  Skin  Diseases,  University  College  Hospital,  London.  Third  Edi- 
tion, Thoroughly  Revised,  with  new  Illustrations.     Just  Ready.  Cloth,  $5.00 

Cuff.      Lectures  on  Medicine  to  Nurses. 
By  Herbert  Edmund  Cuff,  m.d.,  late  Assistant  Medical  Officer,  Stockwell  Fever 
Hospital,  England.     Third  Edition,  Revised.     With  25  Illustrations.        Cloth,  $1.25 


12  P.  BLAKISTON'S  SON  &-    CO:  S 

Gushing.     Compend  of  Histology. 

Specially  adapted  for  the  use  of  Medical  Students  and  Physicians.  By  H.  H.  Cushing, 
M.D.,  Director  of  Histological  and  Embryological  Laboratories,  Woman's  Medical 
College  of  Pennsylvania  ;  Demonstrator  of  Histology  and  Embrj^ology,  Jefferson 
Medical  College,  Philadelphia.  Illustrated.  No.  ij  f  Qidz-Co7npendf  Series. 
i2mo.      In  Press.  Cloth,  .80;  Interleaved  for  Notes,  Ji.oo 

Davis.     Dietotherapy.     Food  in  Health  and  Disease. 

See  Cohen,  Physiologic  Therapeutics,  page  10. 

Davis.     The  Principles  and  Practice  of  Bandaging. 

By  GwiLYM  G.  Davis,  ji.d.,  m.r.c.s..  Universities  of  Pennsylvania  and  Gottingen, 
Assistant  Demonstrator  of  Surger}^  University  of  Pennsylvania  ;  Surgeon  to  the  Out- 
Patient  Departments  of  the  Episcopal  and  Children's  Hospitals  ;  Assistant  Surgeon 
to  the  Orthopeedic  Hospital.  Second  Edition,  Revised  and  Rewritten.  163  Illustra- 
tions, Redrawn  specially  for  this  edition.  Cloth,  $1.50 

Domville.     Manual  for  Nurses 

and  Others  Engaged  in  Attending  to  the  Sick.  By  Ed.  J.  Domville,  m.d.  Ninth 
Edition,  Revised.     With  Recipes  for  Sick-room  Cookery^  etc.      i2mo.  Li  Press. 

Donders.     Refraction.     Portrait  of  Author. 

An  Essay  on  the  Nature  and  the  Consequences  of  Anomalies  of  Refraction.  By  F. 
C.  Donders,  m.d.  Authorized  Translation.  Revised  and  Edited  by  Charles  A. 
Oliver,  a.m.,  m.d.  (Univ.  Pa.),  one  of  the  Attending  Surgeons  to  the  Wills  Eye 
Hospital.     With  a  Portrait  of  the  Author.     Octavo.  Half  Morocco,  Gilt,  $1.25 

Da  Costa.     Clinical  Hematology.     Colored  Plates. 

A  Practical  Guide  to  the  Examination  of  the  Blood  by  Clinical  Methods,  with  Refer- 
ence to  the  Diagnosis  of  Disease.  By  John  C.  Da  Costa,  Jr.,  m.d..  Assistant. 
Demonstrator  of  Clinical  Medicine  in  the  Jefferson  Medical  College,  Philadelphia  ; 
Assistant  in  the  Medical  Clinic,  Jefferson  Medical  College  Hospital ;  Hsematologist 
to  the  German  Hospital.  With  six  Colored  Plates  and  48  other  Illustrations.  Octavo. 
Just  Ready.  Cloth,  $5.00;  Sheep,  $6.00 

Deaver.     Surgical  Anatomy.     499  Full-page  Plates.      Now  Ready. 

A  Treatise  on  Human  Anatomy  in  its  Application  to  the  Practice  of  Medicine  and 
Surger}^  •  By  John  B.  Deaver,  m.d.,  Surgeon-in-Chief  to  the  German  Hospital; 
Surgeon  to  the  Children's  Hospital  and  to  the  Philadelphia  Hospital;  Consulting 
Surgeon  to  St.  Agnes',  St.  Timothy's,  and  Germantown  Hospitals  ;  formerly  Assistant 
Professor  of  Applied  Anatomy,  University  of  Pennsylvania,  etc.  With  499 
very  handsome  Full-page  Illustrations  engraved  from  original  drawings  made  by 
special  artists  from  dissections  prepared  for  the  purpose  in  the  dissecting-rooms  of  the 
University  of  Pennsylvania.  Three  large  volumes.  Royal  square  octavo.  Sold  by 
Subscription.     Orders  taken  for  complete  sets  only.      Description  upon  AppUcation. 

Half  ivlorocco  or  Sheep,  $24.00  ;  Half  Russia,  $27.00 

Synopsis  of  Contents. 
Volume  I. — Upper  Extremity — Back  of  Neck,  Shoulder,  and  Trunk — Cranium 

— Scalp — Face. 
Volume  II. — Neck — Mouth,    Phar>'nx,    Lar>'nx,   Nose — Orbit — Eyeball — Organ 

of  Hearing — Brain — Female  Perineum — Male  Perineum. 
Volume  III. — Abdominal  \szX\. — Abdominal   Cavity — Pelvic    Cavity — Chest — 

Lower  Extremity. 

See  next  page  for  Reviews. 


MEDICAL   AND   SCIENTIFIC  PUBLICATIONS.  13 

Deaver's  Surgical  Anatomy 


The  illustrations,  which  at  the  first  glance  appear  as  the  prominent  feature  of 
the  book-— but  which  in  reahty  do  not  overshadow  the  text — consist  of  a  series  of 
pictures  absolutely  unique  and  fresh.  They  will  bear  comparison  from  an  artistic  point 
of  view  with  any  other  work,  while  from  a  practical  point  of  view  there  is  no  other 
volume  or  series  of  volumes  to  which  they  can  be  compared.  When  originally  an- 
nounced, the  book  was  to  contain  two  hundred  illustrations.  As  the  work  of  prepara- 
tion progressed,  this  number  gradually  increased  to  nearly  five  hundred  full-page 
plates,  many  of  which  contain  more  than  one  figure.  With  the  exception  of 
a  few  minor  pictures  made  from  preparations  in  the  possession  of  the  author,  they  have 
all  been  drawn  by  special  artists  from  dissections  made  for  the  purpose  in  the  dissecting- 
rooms  of  the  University  of  Pennsylvania.  Their  accuracy  cannot  be  questioned,  as 
each  drawing  has  been  submitted  to  the  most  careful  scrutiny. 

From  The  Medical  Record,  New  York. 

**  The  tzdidet  is  not  only  taken  by  easy  and  natural  stages  from  the  more  superficial  to  the 
deeper  regions,  but  the  various  important  regional  landmarks  are  also  indicated  by  schematic 
tracing  upon  the  limbs.  Thus  the  courses  of  arteries,  veins,  and  nerves  are  indicated  in  a  way  that 
makes  the  lesson  strikingly  impressive  and  easily  learned.  No  expense,  evidently,  has  been 
spared  in  the  preparation  of  the  work,  judging  from  the  number  of  full-page  plates  it  contains,  not 
counting  the  smaller  drawings.  Most  of  these  have  been  '  drawn  by  special  artists  from  dissections 
made  for  the  purpose  in  the  dissecting-rooms  of  the  University  of  Pennsylvania.'  In  summing  up 
the  general  excellences  of  this  remarkable  work,  we  can  accord  our  unqualified  praise  for  the 
accurate,  exhaustive,  and  systematic  manner  in  which  the  author  has  carried  out  his  plan,  and  we 
can  commend  it  as  a  model  of  its  kind,  which  must  be  possessed  to  be  appreciated.'^ 

From  The  Philadelphia  Medical  Journal. 

"  Many  members  of  the  profession  to  whom  Dr.  Deaver  is  well  known  either  personally  or  by 
reputation  as  a  surgeon,  writer,  teacher,  and  practical  anatomist,  have  awaited  the  appearance  of 
his  Surgical  Anatomy  with  the  expectation  of  finding  in  it  a  guide  in  this  difficult  branch  of  medi- 
cine of  much  more  than  ordinary  practical  value,  and  their  expectations  will  not  be  disappointed.*' 

From  The  Journal  of  the  American  Medical  Association. 

"  In  order  to  show  its  thoroughness,  it  is  only  necessary  to  mention  that  no  less  than  twelve 
full-page  plates  are  reproduced  in  order  to  accurately  portray  the  surgical  anatomy  of  the  hand, 
and  it  is  doubtful  whether  any  better  description  exists  in  any  work  in  the  English  language." 

From  The  Southern  California  Practitioner, 

"  Aside  from  the  merit  of  this  great  work,  it  will  be  a  delight  to  the  lover  of  books.  Its  gen- 
eral  make-up  shows  the  highest  development  of  the  book-making  art.  The  bibliophile,  when 
holding  one  of  these  volumes  in  his  hands,  would  be  as  careful  with  it  as  though  he  were  handling 
an  infant,  and  to  drop  it  would  cause  him  the  keenest  pain.  The  illustrations,  the  print,  and  the 
paper  and  binding  are  each  and  all  delightful  in  themselves,  and  yet  the  text  is  concise  and  clear, 
and  taken  with  the  illustrations  make  a  remarkably  good  substitute  for  the  dissecting-room.  To 
have  these  three  volumes  on  his  library  shelves  will  be  a  source  of  pride  and  joy  and  profit  to 
every  practitioner.  Dr.  Deaver  has  in  these  volumes  conferred  a  boon  upon  the  medical  profession 
which  has,  at  least,  never  been  surpassed  by  any  one." 

From  The  New  Orleans  Medical  and  Surgical  Journal. 

"  While  the  needs  of  the  undergraduate  have  been  fully  kept  in  view,  it  has  been  the  aim  of 
the  author  to  provide  a  work  which  would  be  sufficient  for  reference  for  use  in  actual  practice.  We 
believe  the  book  fulfils  both  requirements.  The  arrangement  is  systematic  and  the  discussion  d. 
furgical  relations  thorouj^h.'* 

]^^  Large  Descriptive  Circular  will  be  sent  upon  application 


14  P.  BLAKISTON'S  SON  &-    CO:  S 

Deaver.     Appendicitis.     Third  Edition. 

Its  History,  Anatomy,  Etiology,  Pathology,  Symptoms,  Diagnosis,  Prognosis,  Treat- 
ment, Complications,  and  Sequelae.  With  22  Plates,  10  of  which  are  Colored. 
Third  Edition,  Revised  and  Rewritten.  Preparing. 

Dercum.     Rest — Mental  Therapeutics — Suggestion. 

See  Cohen,  Physiologic  Therapeutics,  page  10. 

Douglas.     Surgical  Diseases  of  the  Abdomen. 

By  Richard  Douglas,  m.d.,  late  Professor  of  Gynecology  and  Abdominal  Surgery, 
Medical  Department  Vanderbilt  University  ;  Ex-President  of  the  Southern  Surgical 
and  Gynecological  Association,  etc.  Illustrated  by  19  Full-page  Plates.  Large  Octavo. 
900  pages.  Just  Ready. 

Dlihrssen.     A  Manual  of  Gynecological  Practice. 

By  Dr.  A.  Duhrssen,  Privat-Docent  in  Gynecology  in  the  University  of  Berlin. 
Translated  from  the  Fourth  German  Edition  and  Edited  by  John  W.  Taylor,  f.r.c.s.. 
Surgeon  to  the  Birmingham  and  Midlands  Hospital  for  Women  ;  and  Frederick 
Edge,  m.d.,  f.r.c.s.     With  105  Illustrations.      i2mo.  Cloth,  $1.50 

Dulles.     What  to  Do  First  In  Accidents  and  Poisoning. 

By  C.  W.  Dulles,  m.d.,  Surgeon  to  the  Rush  Hospital  ;  formerly  Assistant  Surgeon 
2d  Regiment  N.  G.  Pa.,  etc.  Fifth  Edition,  Enlarged.  With  new  Illustrations. 
i2mo.  Cloth,  $1.00 

Edgar.     The  Practice  of  Obstetrics. 

By  J.  Clifton  Edgar,  m.d.,  Professor  of  Obstetrics  Medical  Department  of  Cornell 
University,  New  York  City  ;  Physician  to  Mothers'  and  Babies'  Hospital,  and  to  the 
Emergency  Hospital,  etc.  With  many  Illustrations,  a  large  number  of  which  are 
Original.     Octavo.  Nearly  Ready. 

Emery.     A  Handbook  of  Bacteriological  Diagnosis. 

By  W.  d'Este  Emery,  m.d.,  b.Sc.  Lond.,  Lecturer  in  Pathology  and  Bacteriology  in 
the  University  of  Birmingham.     With  tv/o  colored  plates  and  32  other  illustrations. 

Cloth,  1 1. 50 

Fagge.      Practice  of  Medicine. 

A  Text-Book  of  Medicine  by  the  late  C.  Hilton  Fagge,  m.d.  Fourth  Edition, 
Revised  and  Edited  by  P.  H.  Pye-Smith,  m.d..  Consulting  Physician  to  Guy's 
Hospital,  London,  etc.     Two  Vols.     8vo.     Vol.  I,  Cloth,  $6.00  ;  Vol.  II,  Cloth,  $6.00 

Fenwick.     Cancer  of  Stomach. 
By  Samuel  Fenwick,  m.d.,  m.r.c.p..  Physician  to  the  London  Hospital,  etc.,  and 
W-.  SoLTAN  Fenwick,  m.d.,  b.s.  Cloth,  $3.00 

Fick.     Diseases  of  the  Eye  and  Ophthalmoscopy. 

By  Dr.  Eugen  Fick,  University  of  Zurich.  Authorized  Translation  by  A.  B.  Hale, 
M.D.,  Consulting  Ophthalmic  Surgeon  Charity  Hospital,  Chicago  ;  late  Vol.  Assistant 
Imperial  Eye  Clinic,  University  of  Kiel.  Glossary  and  158  Illustrations,  many  of 
which  are  in  Colors.     Svo.  Cloth,  $4.50;  Sheep,  $5.50 

Fillebrown.     A  Text-Book  of  Operative  Dentistry. 

Written  by  invitation  of  the  National  Association  of  Dental  Faculties.  By  Thomas 
Fillebrown,  m.d.,  d.m.d.,  Professor  of  Operative  Dentistry  in  the  Dental  School  of 
Harvard  University.     Illustrated.     Svo.  Cloth,  I2.25 

Fowler's  Dictionary  of  Practical  Medicine. 

By  Various  Writers.  An  Encyclopedia  of  Medicine.  Edited  by  James  Kingston 
Fowler,  m.d.,  f.r.c.p. ,  Senior  Assistant  Physician  to  the  Middlesex  Hospital, 
London.      Svo.  Cloth,  $3.00  ;  Half  Morocco,  14.00 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  15 

Frenkel.     Tabetic  Ataxia. 

Its  Treatment  by  Systematic  Exercise.  By  Dr.  H.  S.  Frenkel.  Authorized  Trans- 
lation by  L.  Freyberger,  m.d.,  m.r.c. P.      132  Illustrations.     Octavo.     Cloth,  $3.00 

Fullerton.     Obstetric  Nursing. 

By  Anna  M.  Fullerton,  m.d.,  Demonstrator  of  Obstetrics  in  the  Woman's  Medical 
College  ;  Obstetrician  and  Gynecologist  to  the  Woman's  Hospital,  Philadelphia,  etc. 
41  Illustrations.      Fifth  Edition,  Revised  and  Enlarged.      i2mo.  Cloth,  $1.00 

Surgical  Nursing. 

Comprising  the  Regular  Course  of  Lectures  upon  Abdominal  Surgery,  Gyne- 
cology, and  General  Surgical  Conditions  delivered  at  the  Training  School  of 
the  Woman's  Hospital,  Philadelphia.  Third  Edition,  Revised.  69  Illustrations. 
i2mo.  Cloth,  1 1. 00 

Gardner.     The  Brewer,  Distiller,  and  Wine  Manufacturer. 

A  Handbook  for  all  interested  in  the  Manufacture  and  Trade  of  Alcohol  and  its 
Compounds.     Edited  by  John  Gardner,  F.c.s.     Illustrated.  Cloth,  $1.50 

Goodall  and  Washbourn.     A  Manual  of  Infectious  Diseases. 

By  Edward  W.  Goodall,  m.d.  (London),  Medical  Superintendent  Eastern  (Fever) 
Hospital,  Homerton,  London,  etc.  ;  and  J.  W.  Washbourn,  f.r.c.p..  Assistant 
Physician  to  Guy's  Hospital  and  Physician  to  the  London  Fever  Hospital.  Illustra- 
ted with  Charts,  Diagrams,  and  Full-page  Plates.  Cloth,  $3.00 

Gould.      The    Illustrated    Dictionary    of    Medicine,    Biology,    and 
Allied  Sciences.     Fifth  Edition. 

Being  an  Exhaustive  Lexicon  of  Medicine  and  those  Sciences  Collateral  to  it : 
Biology  (Zoology  and  Botany),  Chemistry,  Dentistry,  Pharmacology,  Microscopy, 
etc.  By  George  M.  Gould,  a.m.,  m.d..  Editor  of  Americmt  Medicine ;  President, 
1893-94,  American  Academy  of  Medicine,  etc.  With  many  Useful  Tables  and  numer- 
ous Fine  Illustrations.      Large  Square  Octavo.      1633  pages.     Fifth  Edition. 

Full  Sheep  or  Half  Dark-Green  Leather,  $10.00 
With  Thumb  Index,  $11.00  ;  Half  Russia,  Thumb  Index,  $12.00 

"  Few  persons  read  dictionaries  as  Theophile  Gautier  did — for  pleasure  ;  if,  however,  all 
dictionaries  were  as  readable  as  the  one  under  consideration,  his  taste  for  this  kind  of  literature 
would  be  less  singular.  .  .  .  The  book  is  excellently  printed,  and  the  illustrations  are  admir- 
ably executed.  The  binding  is  substantial  and  even  handsome,  but  the  business-like  '  get-up '  of 
the  book  makes  it  well  fitted  for  use  as  well  as  for  the  adornment  of  a  book-shelf." — The  British 
Medical  Journal,  London. 

The  Student's  Medical   Dictionary.      Eleventh  Ed.      Illustrated. 

Enlarged.  Including  all  the  Words  and  Phrases  generally  used  in  Medicine, 
with  their  proper  Pronunciations  and  Definitions,  based  on  Recent  Medical 
Literature.  With  Tables  of  the  Bacilli,  Micrococci,  Leukomains,  Ptomains, 
etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia,  and  Plexuses  ;  Mineral  Springs 
of  the  U.  S.,  etc.,  and  a  new  Table  of  Eponymic  Terms  and  Tests.  Rewritten, 
Enlarged,  and  Improved.    With  many  Illustrations.    Small  octavo.    840  pages. 

Half  Morocco,  $2.50;  Thumb  Index,  $3.00 

"  One  pleasing  feature  of  the  book  is  that  the  reader  can  almost  invariably  find  the  definition 
under  the  word  he  looks  for,  without  being  referred  from  one  place  to  another,  as  is  too  commonly 
the  case  in  medical  dictionaries.  The  tallies  of  the  bacilli,  micrococci,  leukomains,  and  ptomains 
are  excellent,  and  contain  a  large  amount  of  information  in  a  limited  S])ace.  The  anatomical  tables 
are  also  concise  and  clear.  .  .  .  We  should  unhesitatingly  recommend  this  dictionary  to  our 
readers,  feeling  sure  that  it  will  prove  of  much  value  to  them." — The  American  Journal  of 
Medical  Science. 


16  P.  BLAKISTON'S  SON  &-   CO.\S 

Gould.    The  Pocket  Pronouncing  Medical  Lexicon.    Fourth  Edition. 
(30,000  Medical  Words  Pronounced  and  Defined.) 

A  Student's  Pronouncing  Medical  Lexicon.  Containing  all  the  Words,  their  Defini- 
tions and  Pronunciations,  that  the  Student  generally  comes  in  contact  with  ;  also 
elaborate  Tables  of  the  Arteries,  Muscles,  Nerves,  Bacilli,  etc. ,  etc. ;  a  Dose  List  in 
both  English  and  Metric  Systems,  a  new  table  of  Clinical  Eponymic  Terms,  etc., 
arranged  in  a  most  convenient  form  for  reference  and  memorizing.  Thin  64mo. 
(6  X  314'  inches.)  838  pages.  T/i£  System  of  Pronunciation  used  in  this  book  is  very 
simple.  Full  Limp  Leather,  Gilt  Edges,  $1.00  ;  With  Thumb  Index,  $1.25 

'*  This  *  Dictionary  '  is  admirably  suited  to  the  uses  of  the  lecture-room,  or  for  the  purposes  of 
a  medical  defining  vocabulary — many  of  the  words  not  yet  being  found  in  any  other  dictionary, 
large  or  small,  while  all  of  the  words  are  those  of  the  living  medical  literature  of  the  day." — The 
Virginia  Medical  Monthly. 

*^*  145,000  copies  of  Gould's  Dictionaries  have  been  sold. 
Sample  pages  and  descriptive  circulars  of  Gould' s  Dictionaries  free  upon  application. 

Biographic  Clinics. 

The  Origin  of  the  Ill-Health  of  DeOuincy,  Carlyle,  Darwin,  Huxley,  and  Brown- 
ing.     i2mo.     fust  Ready.  Cloth,  ^i.oo 

Borderland  Studies. 

Miscellaneous  Addresses  and  Essays  Pertaining  to  Medicine  and  the  Medical 
Profession,  and  their  Relations  to  General  Science.   350  pages.   i2mo.  Cloth,  $2.00 

Gould  and   Pyle.     Cyclopedia   of  Practical    Medicine  and   Surgery. 
72  Special  Contributors.     Illustrated.     One  Volume. 

A  Concise  Reference  Handbook,  Alphabetically  Arranged,  of  Medicine,  Surgery, 
Obstetrics,  Materia  Medica,  Therapeutics,  and  the  various  specialties,  with  Particular 
Reference  to  Diagnosis  and  Treatment.  Compiled  under  the  Editorial  Supervision 
of  Drs.  George  M.  Gould  and  W.  L.  Pyle.  Illustrated.  Large  Square  Octavo. 
Uniform  with  Gould's  "Illustrated  Dictionary."  Full  Sheep  or  Half  Dark-Green 
Leather,  ^10.00;  With  Thumb  Index,  $11.00;  Half  Russia,  Thumb  Index,  $12.00 

*^*  The  great  success  of  Dr.  Gould' s  ' '  Illustrated  Dictionary  of  Medicine ' '  sug- 
gested the  preparation  of  this  companion  volume,  which  should  be  to  the  physician  the 
same  trustworthy  handbook  in  the  broad  field  of  general  information  that  the  Dictionary 
is  in  the  more  special  one  of  the  explanation  of  words  and  the  statement  of  facts.  The 
aim  has  been  to  provide  in  a  one-volume  book  all  the  material  usually  contained  in  the 
large  systems  and  much  which  they  do  not  contain.  Instead  of  long,  discursive  papers 
on  special  subjects  there  are  short,  concise,  pithy  articles  alphabetically  arranged,  giv- 
ing the  latest  methods  of  diagnosis,  treatment,  and  operating — a  working  book  in  which 
the  editors  and  their  collaborators  have  condensed  all  that  is  essential  from  a  vast 
amount  of  literature  and  personal  experience. 

The  seventy-two  special  contributors  have  been  selected  from  all  parts  of  the 
country  in  accordance  with  their  fitness  for  treating  special  subjects  about  which  they 
may  be  considered  expert  authorities.  They  are  all  men  of  prominence,  teachers, 
investigators,  and  writers  of  experience,  who  give  to  the  book  a  character  unequaled  by 
any  other  work  of  the  kind. 

•'The  book  is  a  companion  volume  to  Gould's  'Illustrated  Dictionary  of  Medicine,'  which 
every  physician  should  possess.  With  these  two  books  in  his  library,  every  busy  physician  will  save 
a  vast  amount  of  time  in  having  at  hand  an  instant  reference  cyclopedia  covering  every  subject  in 
surgery  and  medicine."  —  Chicago  Medical  Recorder. 

Pocket  Cyclopedia  of  Medicine  and  Surgery. 

Based  upon  Gould  and  Pyle's  Cyclopedia  of  Practical  Medicine  and  Surgery. 
Uniform  with  Gould's  Pocket  Dictionary. 

Full  Limp  Leather,  Gilt  Edges,  $1.00  ;  With  Thumb  Index,  $1.25 
8^"  See  7iext  page  for  List  of  Contributors. 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS. 


17 


Gould  and   Pyle^s   Cyclopedia  of  Medicine 

LIST  OF  CONTRIBUTORS 


Samuel  W.  Abbott,  A.M.,  M.D.,  Boston. 

James  M.  Anders,  M.D.,  LL.D.,  Phila. 

Joseph  D.  Bryant,  M.D.,  New  York. 

James  B.  Bullitt,  M.D.,  Louisville. 

Charles  H.  Burnett,  A.M.,  M.D.,  Phila. 

J.  Abbott  Cantrell,  M.D.,  Philadelphia. 

Archibald  Church,  M  D.,  Chicago. 

L.  Pierce  Clark,  M.D.,  Sonyea,  N.  Y. 

Solomon  Solis-Cohen,  M.D.,  Philadelphia. 

Nathan  S.  Davis,  Jr.,  M.D.,  Chicago. 

Theodore  Diller,  M.D.,  Pittsburg. 

Augustus  A.  Eshner,  M.D.,  Philadelphia. 

J.  T.  Eskridge,  M.D.,  Denver,  Col. 

J.  McFadden  Gaston,  A. B.,  M.D.,  Atlanta, 
Ga. 

J.  McFadden  Gaston,  Jr.,  A.M.,  M.D.,  At- 
lanta, Ga. 

Virgil  P.  Gibney,  M.D.,  New  York. 

George  M.  Gould,  A.M.,  M.D.,  Phila. 

W.  A.  Hardaway,  A.M.,  M.D.,  St.  Louis. 

John  C.  Hemmeter,  M.B.,  M.D.,  Baltimore. 

Barton  Cooke  Hirst,  M.D.,  Philadelphia. 

Bayard  Holmes,  M.D.,  Chicago. 

Orville  Horwitz,  B.S.,  M.D.,  Philadelphia. 

Daniel  E.  Hughes,  M.D.,  Philadelphia. 

James  Nevins  Hyde,  A.M.,  M.D.,  Chicago. 

E.  Fletcher  Ingals,  A.M.,  M.D.,  Chicago. 

Abraham  Jacobi,  M.D.,  New  York. 

William  W.  Johnston,  M.D.,  Washington, 
D.  C. 

Wyatt  Johnston,  M.D.,  Montreal. 

Allen  A.Jones,  M.D.,  Buffalo. 

William  W.  Keen,  M.D.,  LL.D.,  Phila. 

Howard  S.  Kinne,  M.D.,  Philadelphia. 

Ernest  Laplace,  M.D.,  Philadelphia. 

Benjamin  Lee,  M.D.,  Philadelphia. 

Charles  L.  Leonard,  M.D.,  Philadelphia. 

James  Hendrie  Lloyd,  A.M.,  M.D.,  Phila. 

J.  W.  MacDonald,  M.D.  (Edin.),  F.R.C.S. 
Ed.,  Minneapolis. 

L.  S.  McMurtry,  M.D.,  Louisville, 

G.  Hudson  Makuen,  Philadelphia. 


Matthew  D.  Mann,  M.D.,  Buffalo. 
Henry    O.    Marcy,    A.M.,    M.D.,     LL.D., 
Boston. 

Rudolph  Matas,  M.D.,  New  Orleans. 
Joseph  M.  Mathews,  M.D.,  Louisville. 
John  K.  Mitchell,  M.D.,  Philadelphia, 
Harold  N.  Moyer,  M.D.,  Chicago. 
John  H.  Musser,  M.D.,  Philadelphia. 
A.  G.  Nicholls,  M.D.,  Montreal. 

A.  H.     Ohmann-Dusmesnil,     M.D.,     St. 
Louis. 

William  Osier,  M.D.,  Baltimore. 

Samuel   O.    L.  Potter,  A.M.,  M.D.,  M.R. 

C.P.  (London),  San  Francisco. 
Walter  L.  Pyle,  A.M.,  M.D.,  Philadelphia. 

B.  Alexander  Randall,  A.M.,  M.D.,  Phila. 
Joseph  Ransohoff,  M.D.,  F.R.C.S.  (Eng.), 

Cincinnati. 
Jay  F.  Schamberg,  A.M.,  M.D.,  Phila. 
Nicholas  Senn,  M.D.,  LL.D.,  Chicago. 
Richard  Slee,  M.D.,  Swiftwater,  Pa. 
S.    E.    Solly,   M.D.,    M.R.C.S.,    Colorado 

Springs,  Col. 
Edmond  Souchon,  M.D.,  New  Orleans. 
Ward  F.  Sprenkel,  M.D.,  Philadelphia. 
Charles  G.  Stockton,  M.D.,  Buffalo. 
John  Madison  Taylor,  A.M.,  M.D.,  Phila. 
William  S.  Thayer,  M.D.,  Baltimore. 
James  Thorington,  A.M.,  M.D.,  Phila. 
Martin  B.  Tinker,  M.D.,  Philadelphia. 
James  Tyson,  M.D.,  Philadelphia. 
J.  Hilton  W^aterman,  M.D.,  New  York. 
H.  A.  West,  M.D.,  Galveston,  Texas. 
J.  William  White,  M.D.,  PH.D.,  Phila. 
Reynold  W.  Wilcox,  M.A.,  M.D.,  LL.D., 

New  York. 

George  Wilkins,  M.D.,  Montreal. 
DeForest  Willard,  M.D.,  Philadelphia, 
Alfred  C.  Wood,  M.D.,  Philadelphia. 
Horatio  C.  Wood,  M.D.,  LL.D.,  Phila. 
Albert  Woldert,  Ph.G.,  M.D.,  Phila. 
James  K.  Young,  M.D.,  Philadelphia. 


"  It  is  difficult  to  describe  the  vohime  before  us,  and  one  must  imagine  all  that  is  clinical 
at  the  present  day  as  being  briefly  and  yet  sufficiently  set  forth  under  an  alphabetical 
arrangement,  with  frequent  illustrations,  with  many  formula;  and  diagnostic  distinctions,  and 
with  perfect  homogeneity  ;  then  he  will  have  a  fair  picture  of  the  work.  We  feel  sure,  however, 
that  many  of  our  readers  will  make  the  better  acquaintance  of  the  book  by  becoming  its  possessors, 
and  we  commend  it  to  them  without  hesitation.  We  have  yet  to  find  wherein  it  is  erroneous  or 
disappointing,  and  we  regard  it  as  of  unlimited  value  to  the  average  medical  man."  —  The 
Neiv  York  Medical  Journal. 

'^^  Sainple  pages  and  description  tipon  applicatio7i. 


18  F.  BLAKISTON'S  SON  &-   CO.'S 

Gould  and  Pyle.     Compend  of  Diseases  of  the  Eye. 

Including  Refraction  Treatment  and  Operations,  with  a  Section  on  Local  Therapeutics. 
With  Formulce,  Glossary,  and  several  Tables.  By  Drs.  George  M.  Gould  and 
W.  L.  Pyle.  Second  Edition.  109  Illustrations,  several  of  which  are  Colored. 
JVo.  8  f  Quiz- Compend f  Series.  Cloth,  80.;  Interleaved  for  Notes,  $1.00 

Gordinier.  The  Gross  and  Minute  Anatomy  of  the  Central  Nervous 
System.  261  Illustrations. 
By  H.  C.  Gordinier,  a.m.,  m.d..  Professor  of  Physiology  and  of  the  Anatomy  of 
the  Nervous  System  in  the  Albany  Medical  College  ;  Member  American  Neurological 
Association.  With  48  Full-page  Plates  and  213  other  Illustrations,  a  number  of 
which  are  printed  in  Colors  and  many  of  which  are  original.     Large  8vo. 

Handsome  Cloth,  $6.00  ;  Sheep,  $7.00  ;  Half  Russia,  |8.oo 

Gorgas'  Dental  Medicine. 

A  Manual  of  Dental  Materia  Medica  and  Therapeutics.  By  Ferdinand  J.  S.  Gorgas, 
M.D.,  D.D.S.,  Professor  of  the  Principles  of  Dental  Science,  Oral  Surgery,  and  Dental 
Mechanism  in  the  Dental  Department  of  the  University  of  Maryland.  Seventh 
Edition,  Revised  and  Enlarged,  with  many  Formulas.     8vo.     /usi  Ready. 

Cloth,  ^4.00;  Sheep,  ^5.00;  Half  Russia,  $6.00 

Questions  and  Answers. 

Embracing  the  Curriculum  of  the  Dental  Student.  Divided  into  three  parts. 
By  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  Author  of  "Dental  Medicine," 
Editor  of  ' '  Harris'  Principles  and  Practice  of  Dentistry  ' '  and  ' '  Harris'  Dictionary 
of  Medical  Terminology  and  Dental  Surgery,"  Professor  of  the  Principles  of 
Dental  Science,  Oral  Surgery,  etc.,  in  the  University  of  Maryland,  Dental 
Department,  Baltimore,     Octavo.     Just  Ready.  Cloth,  ^6.00 

Gray.     A  Treatise  of  Physics. 

By  Andrew  Gray,  ll.d.,  f.r.s..  Professor  of  Natural  Philosophy  in  the  University 
of  Glasgow.    .  In  Three  Volumes. 

Vol.  I.     Dynamics   and    Properties   of  Matter.     350  Illustrations.     Octavo. 
688  pages.  Cloth,  $4.50 

GreefF.     The  Microscopic  Examination  of  the  Eye. 

By  Professor  R.  Greeff.  Surgeon  to  the  Ophthalmic  Department  of  the  Royal  Charity 
Hospital,  Berlin.  Translated  from  the  Second  German  Edition  by  Hugh  Walker, 
M.A.,  M.D.,  Assistant  Surgeon  and  Pathologist  to  the  Ophthalmic  Department  of  the 
Glasgow  Royal  Infirmary.      i2mo.  Cloth,  $1.25 

Greene.     The  Medical  Examination  for  Life  Insurance 

and  its  Associated  Clinical  Methods.  With  Chapters  on  the  Insurance  of  Sub- 
standard Risks  and  Accident  Insurance.  By  Charles  Lyman  Greene,  m.d.,  of  St. 
Paul,  Clinical  Professor  of  Medicine  and  Physical  Diagnosis  in  the  University  of  Min- 
nesota. With  99  Illustrations,  many  of  which  are  original,  several  being  printed 
in  Colors.     Second  Edition,  Revised.     Octavo.  In  Press. 

Griffith's  Graphic  Clinical  Chart. 

Designed  by  J.  P.  Crozer  Griffith,  m.d.,   Instructor  in  Chnical  Medicine  in  the 
University  of  Pennsylvania.    Sample  copies  free.    Put  up  in  loose  packages  of  50,  .  50 
Price  to  Hospitals:   500  copies,  $4.00;   1000  copies,  I7.50. 

GrofF.     Materia  Medica  for  Nurses. 

With  Questions  for  Self-examination.  By  John  E.  Groff,  Apothecary  in  the  Rhode 
Island  Hospital,  Providence  ;  Professor  of  Materia  Medica,  Botany,  and  Pharma- 
cognosy in  the  Rhode  Island  College  of  Pharmacy.  Second  Edition,  Revised  and 
Improved.      i2mo.     Just  Ready.  Cloth,  $1.25 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  19 

Greenish.      Microscopical  Examination  of  Foods  and  Drugs. 

Being  a  systematically  arranged  Course  of  Practical  Instruction  in  the  Methods 
adopted  in  the  Analysis  of  Foods  and  Drugs  by  means  of  the  Microscope,  iucluding 
a  description  of  the  structure  of  the  more  important.  Designed  for  the  use  of  Analysts, 
Pharmacists,  and  Students  training  for  those  Professions.  By  Henry  G.  Greenish, 
F.i.c,  F.L.S.,  Professor  of  Pharmaceutics  to  the  Pharmaceutical  Society  of  Great 
Britain.     With  many  Illustrations.     Octavo.  Nearly  Ready. 

Groves  and  Thorp.     Chemical  Technology. 

A  New  and  Complete  Work.     The  Application  of  Chemistry  to  the  Arts  and  Manu- 
factures.    Edited  by  Charles  E.   Groves,  f.r.s.,  and  Wm.  Thorp,  b.sc,  f.i.c, 
assisted  by  many  experts.    With  numerous  Illustrations.     Each  volume  sold  separately . 
Vol.      I.     Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates.     Octavo. 

Cloth,  $5.00;   yi  Mor.,  $6.50 

Vol.     II.     Lighting.     Candles,  Oils,   Lamps,  etc.     By  W.  Y.   Dent,  L.  Field, 

BovERTON   Redwood,  and  D.  A.   Louis.     Illustrated. 

Octavo.  Cloth,  $4.00;    i^  Mor.,  $5.50 

Vol.  III.     Gas    Lighting.     By  Charles    Hunt,    Manager  of  the  Birmingham 

Gasworks.     Illustrated.     Octavo. 

Cloth,  $3.50;  ^  Mor.,  $4.50 
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at  the  Battersea  (London)  Polytechnic  ;  and  W.  J.  Dibdin, 
F.I.C,  F.C.S.,  late  Chemist  and  Superintending  Gas  Ex- 
aminer, London  County  Council.  With  10  Plates  and  181 
other  Illustrations.   Octavo.   Cloth,  $3.50  ;  ^  Mor.,  $4.50 

Gowers.      Manual  of  Diseases  of  the  Nervous  System. 
A  Complete  Text-Book.     By  Sir  William  R.  Gowers,  m.d.,  f.r.s..  Physician  to 
National  Hospital  for  the   Paralyzed  and    Epileptic,   etc.     Revised    and    Enlarged. 
With  many  new  Illustrations.     Two  volumes.     Octavo. 

Vol.    I.      Diseases  of  the  Nerves  and  Spinal  Cord. 

Third  Edition.  Cloth,  $4.00  ;  Sheep,  $5.00  ;  Half  Russia,  $6.00 

Vol.  II.     Brain   and   Cranial    Nerves;    General   and    Functional 
Diseases. 

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*^*  This  book  has  been  translated  into  German,  Italian,  and  Spanish.     It  is  pub- 
lished in  London,  Milan,  Bonn,  Barcelona,  and  Philadelphia. 

Syphilis  and  the  Nervous  System. 

Being  a  Revised  Reprint  of  the  Lettsomian  Lectures  for  1890,  delivered  before 
the  Medical  Society  of  London.      i2mo.  Cloth,  $1.00 

Epilepsy  and  Other  Chronic  Convulsive  Diseases. 

Their  Causes,  Symptoms,  and  Treatment     Second  Edition.  Cloth,  $3.00 

Hadley.     General  Medical  and  Surgical  Nursing. 

A  Manual  for  Nurses.  By  Dr.  W.  G.  Hadley,  Physician  to,  and  Lecturer  on 
Medicine  to  the  Nurses  at,  the  London  Hospital.  With  an  Appendix  on  Sick-Room 
Cookery.      i2mo.      326  pages.  Cloth,  $1.25 

Haig.     Causation  of  Disease  by  Uric  Acid.     Sixth  Edition. 

A  Contribution  to  the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy, 
Mental  Depression,  Gout,  Rheumatism,  Diabetes,  Bright' s  Disease,  Anaemia,  etc. 
By  Alexander  Haig,  m.a.,  m.d.  (Oxon.),  f.r.c.p..  Physician  to  MetropoHtan  Hos- 
pital, London.      75  Illustrations.     Fifth  Edition.      8vo.  In  Press. 

Diet  and  Food. 

Considered    in    Relation  to  Strength  and    Power  of  Endurance,   Training  and 
Athletics.     Fourth  Edition,  Revised.      7  Illustrations.  Cloth,  $1.00 


20  P.  BLAKISTON'S  SON  &-   CO.' S 

Hall.     Diseases  of  the  Nose  and  Throat. 

By  F.  DE  Havilland  Hall,  m.d.,  f.r.c.p.  (Lond.),  Physician  to  the  Westminster 
Hospital ;  President  of  the  Laryngological  Society  of  London  ;  Joint  Lecturer  on  the 
Principles  and  Practice  of  Medicine  at  the  Westminster  Hospital ;  and  Herbert 
TiLLEY,  M.D.,  B.s.  (Lond.),  F.R.c.s.  (Eng.),  Surgeon  to  the  Throat  Hospital,  Golden 
Square  ;  Lecturer  on  Diseases  of  the  Nose  and  Throat,  London  Post-Graduate  College 
and  Polyclinic.  Second  Edition,  Revised,  with  2  Plates  and  80  Illustrations.  Cloth,  $2.75 

Hamilton.     Lectures  on  Tumors 

from  a  Clinical  Standpoint.  By  John  B.  Hamilton,  m.d.,  ll.d.,  late  Professor  of 
Surgery  in  Rush  Medical  College,  Chicago  ;  Surgeon  Presbyterian  Hospital,  etc. 
Third  Edition,  Revised.     With  New  Illustrations.      i2mo.  Cloth,  $1.25 

Hansell  and  Sweet.     Diseases  of  the  Eye. 

A  Treatise  on  the  Principles  and  Practice  of  Ophthalmic  Medicine  and  Surgery.  By 
Howard  F.  Hansell,  a.m.,  m.d.,  Chnical  Professor  of  Ophthalmology,  Jefferson 
Medical  College  ;  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine  ;  Ophthalmic  Surgeon,  Philadelphia  Hospital,  etc., 
and  William  M.  Sweet,  m.d.,  Instructor  in  Ophthalmology,  Jefferson  Medical 
College  ;  Assistant  Attending  Surgeon  and  Chief  of  Eye  Clinic,  Jefferson  Medical 
College  Hospital ;  Associate  in  Ophthalmology,  Philadelphia  Polyclinic  ;  Ophthalmic 
Surgeon,  Phoenixville  Hospital,  etc.     With  over  200  Illustrations.  In  Press, 

Hansell  and  Reber.      Muscular  Anomalies  or  the  Eye. 

By  Howard  F.  Hansell,  a.m.,  m.d..  Clinical  Professor  of  Ophthalmology,  Jefferson 
Medical  College  ;  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic,  etc. ;  and 
Wendell  Reber,  m.d..  Instructor  in  Ophthalmology,  Philadelphia  Polyclinic,  etc. 
With  I  Plate  and  28  other  Illustrations.      i2mo.  Cloth,  $\.^o 

Hansell  and  Bell.     Clinical  Ophthalmology. 

By  Howard  F.  Hansell,  a.m.,  m.d.,  and  James  H.  Bell,  m.d.  With  Colored  Plate 
of  Normal  Fundus  and  120  Illustrations.      i2mo.  Cloth,  ^1.50 

Hare.     Mediastinal  Disease. 

The  Pathology,  Clinical  History,  and  Diagnosis  of  Affections  of  the  Mediastinum 
other  than  those  of  the  Heart  and  Aorta.  By  H.  A.  Hare,  m.d..  Professor  of 
Mat.  Med.  and  Therap.  in  Jefferson  Med.  College.     8vo.     Illustrated.     Cloth,  $2.00 

Harlan.     Eyesight 

and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d..  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.     Illustrated.  Cloth,  .40 

Harris'  Principles  and  Practice  of  Dentistry. 

Including  Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery,  and 
Mechanism.  By  Chapin  A.  Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore 
Dental  College;  Author  of  "Dictionary  of  Medical  Terminology  and  Dental  Sur- 
gery." Thirteenth  Edition,  Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas, 
A.M.,  M.D.,  D.D.S.,  Author  of  "Dental  Medicine;"  Professor  of  the  Principles  of 
Dental  Science,  Oral  Surgery,  and  Dental  Mechanism  in  the  University  of  Maryland. 
1250  Illustrations.      11 80  pages.     8vo.  Cloth,  $6.00  ;  Leather,  $7. OO' 

Dictionary  of  Dentistry. 

Including  Definitions  of  such  Words  and  Phrases  of  the  Collateral  Sciences  as 
Pertain  to  the  Art  and  Practice  of  Dentistry.  Sixth  Edition,  Rewritten,  Re- 
vised, and  Enlarged.  By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.,  Author  of 
"  Dental  Medicine  ;"  Editor  of  Harris'  "Principles  and  Practice  of  Dentistry  ;" 
Professor  of  Principles  of  Dental  Science,  Oral  Surgery,  and  Prosthetic  Dentistry 
in  the  University  of  Maryland.     Octavo.  Cloth,  ^5.00  ;  Leather,  $6.00. 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  21 

Hartridge.      Refraction. 

The  Refraction  of  the  Eye.  A  Manual  for  Students.  By  Gustavus  Hartridge, 
F.R.c.s.,  Senior  Surgeon  Royal  Westminster  Ophthalmic  Hospital  ;  Ophthalmic 
Surgeon  to  St.  Bartholomew's  Hospital,  etc.  105  Illustrations  and  Sheet  of  Test 
Types.     Eleventh  Edition,  Revised  and  Enlarged.  Cloth,  $1.50 

On  the  Ophthalmoscope. 

A  Manual  for  Physicians  and  Students.     Fourth  Edition,  Revised.     With  Colored 
Plates  and  68  Wood-cuts.      i2mo.  Cloth,  ^1.50 

Hartshorne.     Our  Homes. 

Their  Situation,  Construction,  Drainage,  etc.  By  Henry  Hartshorne,  m.d.  Illus- 
trated. Cloth,  .40 

Hatfield.     Diseases  of  Children. 

By  Marcus  P.  Hatfield,  Professor  of  Diseases  of  Children,  Chicago  Medical  Col- 
lege. With  a  Colored  Plate.  Third  Edition.  Being  No.  14  ? Quiz-Compend?  Series. 
i2mo.     Just  Ready.  Cloth,  .80;  Interleaved  for  the  Addition  of  Notes,  $1.00 

"  Dr.  Hatfield  seems  to  have  most  thoroughly  appreciated  the  needs  of  students,  and  most 
excellently  has  he  condensed  his  matter  into  available  form.  It  is  in  accord  with  the  most  recent 
teachings,  and  while  brief  and  concise,  is  surprisingly  complete.  .  .  .  It  is  free  from  irritating 
repetition  of  questions  and  answers  which  mars  so  many  of  the  compends  now  in  use.  Written  in 
systematic  form,  the  consideration  of  each  disease  begins  with  its  definition,  and  proceeds  through 
the  usual  subheadings  to  prognosis  and  treatment,  thus  furnishing  a  complete,  readable  text-book." 
— Annals  of  Gynecology  and  Pediatry. 

Heath.      Minor  Surgery  and  Bandaging. 

By  Christopher  Heath,  f.r.c.s.,  Holme  Professor  of  Clinical  Surgery  in  Univer- 
sity College,  London.  Twelfth  Edition,  Revised  and  Enlarged  by  Bilton  Pollard, 
F.R.C.S.,  Surgeon  University  College  Hospital,  London.  With  195  Illustrations, 
Formulae,  Diet  List,  etc.      i2mo.  Cloth,  $1.50 

Practical  Anatomy. 

A  Manual  of  Dissections.     Ninth  edition,  Edited  by  H.  Ernest  Lane,  f.r.c.s. 
With  321  Illustrations,  of  which  32  are  Colored.  Cloth,  $4.25 

Clinical.  Lectures  on  Surgical  Subjects. 

Second  series.     Delivered  at  University  College  Hospital.  Cloth,  $2.00 

Hedley.     Therapeutic  Electricity  and  Practical  Muscle  Testing. 
By  W.  S.  Hedley,  m.d.,  m.r.c.s.,  in  charge  of  the  Electrotherapeutic  Department 
of  the  London  Hospital.     99  Illustrations.     Octavo.  Cloth,  I2.50 

Heller.     Essentials  of  Materia  Medica,  Pharmacy,  and  Prescription 

Writing. 

By  Edwin  A.  Heller,  m.d.,  Quiz-Master  in  Materia  Medica  and  Pharmacy  at  the 
Medical  Institute,  University  of  Pennsylvania.      i2mo.  Cloth,  $1.50 

Henry.     Anaemia. 

A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d.,  Physician  to  Episcopal  Hospital, 
Philadelphia.  Half  Cloth,  .50 

Heusler.     The  Terpenes. 

By  Fr.  Heusler,  ph.d.,  Privatdocent  of  Chemistry  in  the  University  at  Bonn. 
Authorized  Translation  and  Revision  by  F.  J.  Pond,  PH.D.,  Assistant  Professor  of 
Chemistry,  Pennsylvania  State  College.  Cloth,  ^4.00 


22  P.  BLAKISTON'S  SON  &-    CO: S 

Hemmeter.     Diseases  of  the  Stomach.     Third  Edition. 

Their  Special  Pathology,  Diagnosis,  and  Treatment.  V/ith  Sections  on  Anatomy, 
Analysis  of  Stomach  Contents,  Dietetics,  Surgery  of  the  Stomach,  etc.  By  John  C. 
Hemmeter,  m.d.,  philos.d.,  Professor  in  the  Medical  Department  of  the  University 
of  Maryland  ;  Consultant  to  the  University  Hospital  ;  Director  of  the  Clinical  Labor- 
atory, etc. ;  formerly  Clinical  Professor  of  Medicine  at  the  Baltimore  Medical  College, 
etc.  Third  Edition,  Revised.  With  15  Plates  and  41  other  Illustrations,  some  of 
which  are  in  Colors.  Cloth,  $6.00;  Leather,  $7.00;  Half  Russia,  $8. 00 

Diseases  of  the  Intestines. 

A  Complete  Systematic  Treatise  on  Diseases  of  the  Intestines,  including  their 
Special  Pathology,  Diagnosis,  and  Treatment,  with  Sections  on  Anatomy  and 
Physiology,  Microscopic  and  Chemic  Examination  of  the  Intestinal  Contents, 
Secretions,  Feces,  and  Urine.  Intestinal  Bacteria  and  Parasites  ;  Surgery  of  the 
Intestines  ;  Dietetics,  Diseases  of  the  Rectum,  etc.  With  many  Full-page  Plates, 
Colored  and  other  Illustrations,  most  of  which  are  Original.  2  vols.  Octavo. 
Just  Ready.  Vol.   I.      Cloth,  $5.00;  Sheep,  0.oo 

Vol.  II.  Cloth,  $5.00;  Sheep,  $6.00 
The  Section  on  Anatomy  has  been  prepared  by  Dr.  J.  Holmes  Smith,  Associate 
Professor  and  Demonstrator  of  Anatomy,  and  Lecturer  on  Clinical  Surgery,  University 
of  Maryland,  Baltimore.  The  Section  on  Bacteria  of  the  Intestines  has  been 
prepared  by  IDr.  Wm.  Royal  Stokes,  Associate  Professor  of  Pathology  and  Bacteriology, 
and  Visiting  Pathologist  to  the  University  Hospital,  University  of  Maiyland,  Baltimore. 
The  Section  on  Diseases  of  the  Rectum  has  been  prepared  by  Dr.  Thomas  C. 
Martin,  Professor  of  Proctology,  Cleveland  College  of  Physicians  and  Surgeons.  The 
Section  on  Examination  of  Urine  and  Feces  has  been  prepared  by  Dr.  Harry 
Adler,  Demonstrator  of  Clinical  Pathology,  Associate  Professor  of  Diseases  of  the 
Stomach  and  Intestines,  University  of  Maryland,  Baltimore.  The  Illustrations  form 
a  most  useful  and  practical  series  of  pictures, — nearly  all  have  been  reproduced  from 
pathological  preparations  and  original  drawings,  a  few  being  printed  in  several  colors. 

Hewlett.     Manual  of  Bacteriology.    .  75  Illustrations. 

By  R.  T.  Heavlett,  m.d.,  m.r.c.p..  Assistant  Bacteriologist  British  Institute  of  Pre- 
ventive Medicine,  etc.     Second  Edition,  Revised.     Just  Ready.  Cloth,  $4.00 

Hollopeter.     Hay  Fever  and  Its  Successful  Treatment. 

By  W.  C.  Hollopeter,  a.m.,  m.d..  Clinical  Professor  of  Pediatrics  in  the  Medico- 
Chirurgical  College  of  Philadelphia  ;  Physician  to  the  Methodist  Episcopal,  Medico- 
Chirurgical,  and  St.  Joseph's  Hospitals,  etc.     Second  Edition.     i2mo.       Cloth,  $1.00 

Holden's  Anatomy.     Seventh  Edition. 

A  Manual  of  the  Dissections  of  the  Human  Body.  By  John  Langton,  f.r.c.s., 
Surgeon  to,  and  Lecturer  on  Anatomy  at,  St.  Bartholomew's  Hospital.  Carefully 
Revised  by  A.  Hewson,  m.d..  Demonstrator  of  Anatomy,  Jefferson  Medical  College, 
Philadelphia,  etc.      320  Illustrations.     Two  small  compact  volumes.      i2mo. 

Vol.    I.     Scalp,  Face,  Orbit,  Neck,  Throat,  Thorax,  LTpper  Extremity.     435  pages. 

153  Illustrations.  Oil  Cloth,  $1.50 

Vol.  II.     Abdomen,    Perineum,    Lower    Extremity,   Brain,    Eye,    Ear,    Mammary 

Gland,  Scrotum,  Testes.     445  pages.      167  Illustrations. 

Oil  Cloth,  $1.50 

Human  Osteology. 

Comprising  a  Description  of  the  Bones,  with  Colored  Delineations  of  the  Attach- 
ments of  the  Muscles.  The  General  and  Microscopical  Structure  of  Bone  and 
its  Development.  Eighth  Edition,  Carefully  Revised.  Edited  by  Charles 
Stewart,  f.r.s.,  and  R.  W.  Reid,  m.d.,  f.r.c.s.  With  Colored  Lithographic 
Plates  and  Numerous  Illustrations.  Cloth,  $5.25 

Landmarks. 

Medical  and  Surgical.     Fourth  Edition.      8vo.  Cloth,  .75 


.      MEDICAL   AND   SCIENTIFIC  PUBLICATIONS.  23 

Holland.     The  Urine,  the  Gastric  Contents,  the  Common  Poisons, 

and  the  Milk.     Illustrated. 

Memoranda  (Chemical  and  Microscopical)  for  Laboratory'  Use.  By  J.  W.  Holland, 
M.D.,  Professor  of  Medical  Chemistry  and  Toxicology  in  Jefferson  Medical  College 
of  Philadelphia.     Sixth  Edition,  Enlarged.      Illustrated  and  Interleaved.      i2mo. 

Horwitz's  Compend  of  Surgery.  ^^°*'  ^'-^^ 

Including  Minor  Surgery,  Amputations,  Bandaging,  Fractures,  Dislocations,  Surgical 
Diseases,  etc.,  with  Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz, 
B.S.,  M.D.,  Professor  of  Genito-Urinary  Diseases,  late  Demonstrator  of  Surgery, 
Jefferson  Medical  College.  Fifth  Edition.  167  Illustrations  and  98  Formulas.  i2mo. 
No.  g  ?Qiciz-Coinpe7id  ?  Series.  Cloth,  .80;  Interleaved  for  Notes,  $1.00 

*^*  A  SpaJiish  translation  of  this  book  has  recently  been  published  in  Barcelotta. 

Horsley.     The  Brain  and  Spinal  Cord, 
the  Structure  and  Functions  of.     By  Victor  A.   Horsley,   m.b.,  f.r.s.,   etc.,  As- 
sistant Surgeon  University  College  Hospital,  London,  etc.      Illustrated.     Cloth,  $2.50 

Hovell.     Diseases  of  the  Ear  and  Naso-Pharynx. 

A  Treatise  including  Anatomy  and  Physiology  of  the  Organ,  together  with  the  treat- 
ment of  the  affections  of  the  Nose  and  Pharynx  which  conduce  to  aural  disease.  By 
T.  Mark  Hovell,  f.r.c.s.  (Edin.),  m.r.c.s.  (Eng.),  Aural  Surgeon  to  the  London 
Hospital  for  Diseases  of  the  Throat,  etc.      128  Illus.     Second  Edition.     Cloth,  I5.50 

Humphrey.     A  Manual  for  Nurses.     Twenty-fourth  Edition. 

Including  General  Anatomy  and  Physiology,  Management  of  the  Sick-room,  etc.  By 
Laurence  Humphrey,  m.a.,  m.b.,  m.r.c.s.,  Assistant  Physician  to  Addenbrook's 
Hospital,  Cambridge,  England.     23d  Edition.     i2mo.     79  Illustrations.     Cloth,  $1.00 

Hughes  and  Keith.     Dissections.     Illustrated. 

A  Manual  of  Dissections  by  Alfred  W.  Hughes,  m.b.,  m.r.c.s.  (Edin.),  late  Pro- 
fessor of  Anatomy  and  Dean  of  Medical  Faculty,  King's  College,  London,  etc.,  and 
Arthur  Keith,  m.d..  Lecturer  on  Anatomy,  London  Hospital  Medical  College,  etc. 
In  three  parts,  with  many  Colored  and  other  Illustrations. 

I.   Upper  and  Lower  Extremity.    38  Plates,  116  other  Illustrations.     Just  Ready. 

Cloth,  1:3.00 
II.  Abdomen.     Thorax.     4  Plates,  149  other  Illus.     Just  Ready.        Cloth,  $3.00 
III.   Head,  Neck,  and  Central  Nervous  System.      16  Plates  and  204  other  Illustra- 
tions.    Just  Ready.  Cloth,  $3.00 

Hughes.      Compend  of  the  Practice  of  Medicine.     Sixth  Edition. 

Giving  the  Synonyms,  Definition,  Causes,  Symptoms,  Pathology,  Prognosis,  Diag- 
nosis, Treatment,  etc.,  of  each  Disease.  The  Treatment  is  especially  full  and  a 
number  of  valuable  Prescriptions  have  been  incorporated.  Sixth  Edition,  Revised 
and  Enlarged.  By  Daniel  E.  Hughes,  m.d.,  Chief  Resident  Physician  Philadel- 
phia Hospital ;  formerly  Demonstrator  of  Clinical  Medicine  at  Jefferson  Medical 
College,  Philadelphia.     Beiiig  Nos.  2  and 3  f  Quiz- Co77ip end?  Series. 

Quiz-Compend  Edition,  in  two  Parts. 

Part  I. — Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the  Mouth, 
Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  Blood,  etc., 
Parasites,  etc.,  and  General  Diseases,  etc. 

Part  II. — Physical  Diagnosis,  Diseases  of  the  Respiratory  System,  Circulatory 
System,  Diseases  of  the  Brain  and  Nervous  System,  Mental  Diseases,  etc. 

Price  of  each  Part,  in  Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  $1.00 

Physicians'  Edition. 

In  one  volume,  including  the  above  two  parts,  a  Section  on  Skin  Diseases,  and 
an  Index.     Sixth  Revised  atid  Enlarged  Edition.     62^  pages. 

Full  Morocco,  Gilt  Edges,  Round  Corners,  ^2.25 


24  P.  BLAKISTON'S  SON  &-    CO.' S 

Ireland.     The  Mental  Affections  of  Children. 

Idiocy,  Imbecility,  Insanity,  etc.  By  W.  W.  Ireland,  m.d.  (Edin.),  of  the  Home 
and  School  for  Imbeciles,  Mavisbush,  Scotland  ;  Second  Edition,  Revised  and  En- 
larged. Cloth,  $4.00 

Jacoby.     Electrotherapy.      Illustrated. 

See  Cohen,  Physiologic  Therapeutics,  page  9. 

Jacobson.     The  Operations  of  Surgery. 

By  W.  H.  A.  Jacobson,  f.r.c.s.  (Eng.),  Surgeon  Guy's  Hospital,  etc.,  and  F.  J. 
Steward,  f.r.c.s..  Assistant  Surgeon  Guy's  Hospital  and  the  Hospital  for  Sick  Chil- 
dren, Great  Ormand  Street,  London.  With  550  Illustrations.  Fourth  Edition, 
Revised  and  Enlarged.     Two  volumes.     Octavo.      1524  pages. 

Cloth,  $10.00;  Leather,  $12.00 

Jennings.     A  Manual  of  Ophthalmoscopy. 

By  J.  E.  Jennings,  m.d.  (Univ.  Penna.),  Formerly  Clinical  Assistant  Royal  London 
Ophthalmic  Hospital,  London  ;  Fellow  of  the  British  Laryngological  and  Rhinological 
Association  ;  Member  of  the  American  Medical  Association  ;  Member  of  the  St. 
Louis  Medical  Society,  etc.     With  95  Illustrations  and  i  Colored  Plate,    /t^s^  Ready. 

Cloth,  $1.50 

Jones.      Medical  Electricity.     Third  Edition. 

A  Practical  Handbook  for  Students  and  Practitioners  of  Medicine.  By  H.  Lewis 
Jones,  m.a.,  m.d.,  f.r.c.p..  Medical  Officer  in  Charge  Electrical  Department,  St. 
Bartholomew's  Hospital.  Third  Edition  of  Steavenson  and  Jones'  Medical  Elec- 
tricity, Revised  and  Enlarged.      1 1 7  Illustrations.      532  pages.      i2mo.     Cloth,  $3.00 

Jones.     Outlines  of  Physiology. 

By  Edward  Groves  Jones,  m.d.,  Assistant  Professor  of  Physiology  and  Pathological 
Anatomy,  Atlanta  College  of  Physicians    and    Surgeons.      96  Illustrations.      i2mo. 

Cloth,  $1.50 

Keay.     Gail-Stones. 

The  Medical  Treatment  of  Gall-Stones.  By  J.  H.  Keay,  m.a.,  m.d..  Physician  to 
Trinity  Hospital,  Greenwich,  London.      i2mo.  Cloth,  §1.25 

Keen.     Clinical  Charts. 

A  Series  of  Seven  Outline  Drawings  of  the  Human  Body,  on  which  may  be  marked 
the  course  of  any  Disease,  Fractures,  Operations,  etc.  By  W.  W.  Keen,  m.d., 
Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College. 
Each  Drawing  may  be  had  separately  gummed  on  back  for  pasting  in  case  book. 
25  to  the  pad.    Price,  25  cents.    Special  Charts  will  be  printed  to  order.    Samples  free. 

Kehr.     Diagnosis  of  Gall-Stone  Disease. 

Including  one  hundred  Clinical  and  Operative  Cases  illustrating  Diagnostic  Points  of 
the  Different  Forms  of  the  Disease.  By  Prof.  Dr.  Hans  Kehr,  of  Halberstadt. 
Authorized  Translation  by  William  WoTKYNS  Seymour,  a.b.  (Yale),  m.d.  (Harvard), 
of  Troy,  N.  Y.      i2mo.      370  pages.  Cloth,  $2.50 

Kenwood.     Public  Health  Laboratory  Work. 

By  H.  R.  Kenwood,  m.b.,  d.p.h.,  f.c.s.,  Assistant  Professor  of  Pubhc  Health, 
University  College,  London,  etc.      116  Illustrations  and  3  Plates.  Cloth,  $2.00 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  25 

Kirkes*  Physiology.     Seventeenth  Edition. 

{The  only  Authorized  Edition.  i2mo.  Dark  Red  Cloth.)  A  Handbook  of  Physiology. 
Seventeenth  London  Edition,  Revised  and  Enlarged.  By  W.  D.  Halliburton,  m.d., 
F.R.S.,  Professor  of  Physiology,  King's  College,  London.  Thoroughly  Revised  and 
in  many  parts  Rewritten.  68 1  Illustrations,  a  number  of  which  are  printed  in  Colors. 
888  pages.      i2mo.  Cloth,  $3.00  ;  Leather,  $3.75 

IMPORTANT   NOTICE.     This  is  the  identical  Edition  of  "  Kirkes'  Physiology,"  as  published  in 

London  by  John  Murray,  the  sole  owner  of  the  book,  and  containing 

the  revisions  and  additions  of  Dr.  Hallibxirton,  and  the  new  and  original  illustrations  included  at 
his  suggestion.     This  edition  has  been  carefully  and  thoroughly  revised. 

Kleen.      Diabetes  Mellitus  and  Glycosuria. 
Their  Diagnosis  and  Treatment.     By  Dr.  Emil  Kleen.     Octavo.  Cloth,   $2.50 

Knight.     Diseases  of  the  Throat. 

A  Manual  for  Students.  By  Charles  H.  Knight,  m.d.,  Professor  of  Laryngology, 
Cornell  University  Medical  College  ;  Surgeon  to  Throat  Department,  Manhattan  Eye 
and  Ear  Hospital,  etc.      Illustrated.  Neariy  Ready. 

Knopf.     Pulmonary  Tuberculosis.      Its  Modern  Prophylaxis  and  the 
Treatment  in  Special  Institutions  and  at  Home. 

By  S.  A.  Knopf,  m.d..  Physician  to  the  Lung  Department  of  the  New  York  Throat 
and  Nose  Hospital ;  former  Assistant  Physician  to  Professor  Dettweiler,  Falkenstein 
Sanatorium,  Germany,  etc.      Illustrated.     Octavo.  Cloth,  $3.00 

Kyle.     Diseases  of  the  Ear,  Nose,  and  Throat. 
A  Compend  for  Students  and  Physicians.     By  John  J.  Kyle,  m.d.     Illus.     In  Press. 

Landis'  Compend  of  Obstetrics. 

By  Henry  G.  Landis,  m.d.  Seventh  Edition,  Revised  by  Wm.  H.  Wells,  m.d., 
Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College  ;  Member  Obstetrical 
Society  of  Philadelphia,  etc.     With  52  Illustrations.     No.  j  ? Quiz- Compend?  Series. 

Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  |i.oo 

Landois.     A  Text-Book  of  Human  Physiology. 

Including  Histology  and  Microscopical  Anatomy,  with  Special  Reference  to  the  Re- 
quirements of  Practical  Medicine.  By  Dr.  L.  Landois,  Professor  of  Physiology  and 
Director  of  the  Physiological  Institute  in  the  University  of  Greifswald.  Fifth  Ameri- 
can translated  from  the  last  German  Edition,  with  Additions,  by  Wm.  Stirling, 
M.D.,  d.Sc,  Brackenbury  Professor  of  Physiology  and  Histology  in  Owens  College, 
and  Professor  in  Victoria  University,  Manchester.  With  845  Illustrations,  many  of 
which  are  printed  in  Colors.     8vo.  In  Press. 

Lazarus-Barlow.     Pathological  Anatomy  and  Histology. 

By  W.  S.  Lazarus-Barlow,  m.d..  Demonstrator  of  Pathology  at  the  University  of 
Cainbridge,  England.  With  7  Colored  Plates  containing  19  figures  and  171  other 
Illustrations.     Octavo.  Cloth,  $6.50 

Lee.     The  Microtomist's  Vade  Mecum.     Fifth  Edition. 

A  Handbook  of  the  Methods  of  Microscopic  Anatomy.  By  Arthur  Bolles  Lee, 
formerly  Assistant  in  the  Russian  Laboratory  of  Zoology  at  Villefranche-sur-Mer  (Nice). 
894  Articles.     Enlarged,  Revised,  and  Rearranged.      532  pages.     8vo.     Cloth,  $4.00 

Leffmann  and  Beam.  Food  Analysis.  Illustrated. 
Select  Methods  in  Food  Analysis.  By  Henry  Leffmann,  m.d..  Professor  of  Chem- 
istry in  the  Woman's  Medical  College  of  Pennsylvania  and  in  the  Wagner  Free 
Institute  of  Science  ;  Pathological  Chemist,  Jefferson  Medical  College  Hospital,  Phila- 
delphia ;  Vice-President  (190 1 )  Society  Public  Analysts,  etc.;  and  William  Beam, 
a.m.     With  many  Tables,  4  Plates  and  53  other  Illustrations.      i2mo.     Cloth,  $2.50 


26  P.  BLAKISTON'S  SON  6-    CO:  S 

LefFmann.     Compend  of  Medical  Chemistry. 

Inorganic  and  Organic.  Including  Urine  Analysis.  By  Henry  Leffmann,  m.d., 
Professor  of  Chemistry  in  the  Woman' s  Medical  College  of  Pennsylvania  and  in  the 
Wagner  Free  Institute  of  Science,  Philadelphia  ;  Pathological  Chemist  Jefferson  Medi- 
cal College  Hospital,  etc.    No.  lo  ? Quiz- Co7np end?  Series.    Fourth  Edition,  Rewritten. 

Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  $1.00 

The  Coal-Tar  Colors. 

With  Special  Reference  to  their  Injurious  Qualities  and  the  Restrictions  of  their 
Use.     A  Translation  of  Theodore  Weyl's  Monograph.      i2mo.  Cloth,  ^1.25 

Examination  of  Water 

for  Sanitary  and  Technical  Purposes.  Fourth  Edition,  Enlarged.  Illustrated. 
i2mo.  Cloth,  ^1.25 

Analysis  of  Milk  and  Milk  Products. 

Arranged  to  suit  the  needs  of  Analytical  Chemists,  Dairymen,  and  Milk  Inspec- 
tors.    Second  Edition,  Revised  and  Enlarged.     Illustrated.     i2mo.     Cloth,  ^1.25 

Handbook  of  Structural  Formulas 

for  the  Use  of  Students,  containing  180  Structural  and  Stereo-chemic  Formulas. 

i2mo.     Interleaved.  Cloth,  $1.00 

Lewers.     On  the  Diseases  of  Women. 

A  Practical  Treatise.     By  Dr.  A.  H.  N.  Lewers,  Obstetric  Physician  to  the  London 

Hospital.      146  Engravings.     Fifth  Edition,  Revised.  Cloth,  ^2.50 

Cancer  of  the  Uterus. 

A  Clinical  Monograph  on  its  Diagnosis  and  Treatment,  with  the  After-Results 
in  Seventy-three  Cases  Treated  by  Radical  Operation.  With  51  Original  Illus- 
trations and  3  Colored  Plates.     8vo.      328  pages.  Cloth,  $3.00 

Lewis  (Bevan).      Mental  Diseases. 

A  Text-Book  having  Special  Reference  to  the  Pathological  Aspects  of  Insanity,  By 
Bevan  Lewis,  l.r.c.p.,  m.r.c.s..  Medical  Director  West  Riding  Asylum,  Wake- 
field, England.  26  Lithograph  Plates  and  other  Illustrations.  Second  Edition,  Re- 
vised and  Enlarged.     8vo.  Cloth,  $7.00 

Lincoln.     School  and  Industrial  Hygiene. 

By  D.  Y.  Lincoln,  m.d.  Cloth,  .40 

Longley's  Pocket  Medical  Dictionary. 

Giving  the  Definition  and  Pronunciation  of  Words  and  Terms  in  General  Use  in 
Medicine.  With  an  Appendix,  containing  Poisons  and  their  Antidotes,  Abbreviations 
Used  in  Prescriptions,  etc.   By  Elias  Longley.   Cloth,  .75  ;  Tucks  and  Pocket,  ^i.oo 

MacaHster's  Human  Anatomy.      816  Illustrations. 

Systematic  and  Topographical,  including  the  Embryology,  Histology,  and  Mor- 
phology of  Man.  With  Special  Reference  to  the  Requirements  of  Practical  Surgery 
and  Medicine.  By  Alex.  Macalister,  m.d.,  f.r.s.,  Professor  of  Anatomy  in  the 
University  of  Cambridge.     816  Illustrations.     Octavo.     Cloth,  $5.00  ;  Leather,  $6.00 

MacLeod.     Practical  Handbook  of  the  Pathology  of  the  Skin. 

An  Introduction  to  the  Histology,  Pathology,  and  Bacteriology  of  the  Skin,  with 
special  reference  to  Technique.  By  J.  M.  H.  MacLeod,  m.a.,  m.d.,  m.r.c.p.. 
Assistant  in  the  Dermatological  Department,  Charing  Cross  Hospital  ;  Physician  to 
the  Skin  Department,  Victoria  Hospital  for  Children.  With  8  Colored  and  32  Black 
and  White  Plates.     Octavo.     Just  Ready.  Cloth,  ;f 5. 00 

McBride.     Diseases  of  the  Throat,  Nose,  and  Ear. 

A  Clinical  Manual  for  Students  and  Practitioners.  By  P.  McBride,  m.d.,  f.r.C.p. 
(Edin.)  ;  Lecturer  on  Diseases  of  Throat  and  Ear,  Edinburgh  School  of  Medicine, 
etc.  With  Colored  Illustrations  from  Original  Drawings.  Third  Edition,  Revised 
and  Enlarged.     Octavo.  Cloth,  Gilt  Top,  $7.00 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  27 

McCook.     American  Spiders  and  Their  Spinning  Work. 

A  Natural  History  of  the  Orb  weaving  Spiders  of  the  United  States.  By  Henry  C. 
McCooK,  D.D.,  Vice-President  of  the  Academy  of  Natural  Sciences  of  Philadelphia, 
etc.     Three  volumes.      Handsomely  Illustrated  in  Colors.  Cloth,  ^40.00 

Macready.     A  Treatise  on  Ruptures. 
By  Jonathan  F.  C.  H.  Macready,  f.r.c.s.,  Surgeon  to  the  Great  Northern  Central 
Hospital  ;  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest,  etc.      24  Full- 
page  Plates  and  Wood  Engravings.     Octavo.  Cloth,  $6.00 

McFarland.     Prophylaxis — Personal  Hygiene — Nursing  and  Care  of 
the  Sick. 

See  Cohen,  Physiologic  Therapeutics,  page  10. 

McMurrich.     The  Development  of  the  Human  Body. 

A  Manual  of  Human  Embryology.  By  J.  Playfair  McMurrich,  a.m.,  PH.D., 
Professor  of  Anatomy,  Medical  Department  of  the  University  of  Michigan,  Ann  Arbor. 
276  Illustrations.  Cloth,  $3.00 

Makins.     Surgical  Experiences  in  South  Africa,  1899— 1900. 

Being  mainly  a  Clinical  Study  of  the  Effects  of  Injuries  Produced  by  Bullets  of  Small 
Calibre.  By  George  Henry  Makins,  f.r.c.s.,  Surgeon  to  St.  Thomas's  Hospital, 
London  ;  and  late  one  of  the  Consulting  Surgeons  to  the  South  African  Field  Force. 
With  25  Plates  and  96  other  Illustrations.     Octavo.  Cloth,  $4.00 

Mann.     Forensic  Medicine  and  Toxicology. 

By  J.  Dixon  Mann,  m.d.,  f.r.c.p.,  Professor  of  Medical  Jurisprudence  and  Toxi- 
cology in  Owens  College,  Manchester,  etc.     Illustrated.     Octavo.  Cloth,  %6. 50 

Mann's  Manual  of  Psychological  Medicine 

and  Allied  Nervous  Diseases.  Their  Diagnosis,  Pathology,  Prognosis,  and  Treat- 
ment, including  their  Medico-Legal  Aspects.  With  Chapter  on  Expert  Testimony  and 
an  Abstract  of  the  Laws  Relating  to  the  Insane  in  all  the  States  of  the  Union.  By 
Edward  Q.  Mann,  m.d.     With  Illustrations.     Octavo.  Cloth,  $3.00 

Marshall's  Physiological  Diagrams,  Life  Size,  Colored. 

Eleven  Life-size  Diagrams  (each  7  feet  by  3  feet  7  inches).  Designed  for  Demon- 
stration before  the  Class.  By  John  Marshall,  f.r.s.,  f.r.c.s..  Professor  of 
Anatomy  to  the  Royal  Academy  ;  Professor  of  Surgery,  University  College,  London, 
etc.  In  Sheets,  5^40.00  ;  Backed  with  Muslin  and  Mounted  on  Rollers,  $60.00 

Ditto,  Spring  Rollers,  in  Handsome  Walnut  Map  Case,  $100.00 
Single  Plates,  Sheets,  $5.00;  Mounted,  $7.50;  Explanatory  Key,  50  cents. 

Purchaser  nmsi  pay  freight  charges. 

No.  I — The  Skeleton  and  Ligaments.  No.  2 — The  Muscles  and  Joints,  with  Ani- 
mal Mechanics.  No.  3 — The  Viscera  in  Position.  No.  4 — The  Heart  and  Principal 
Blood-vessels.  No.  5 — The  Lymphatics.  No.  6 — The  Digestive  Organs.  No.  7 — The 
Brain  and  Nerves.  Nos.  8  and  9 — The  Organs  of  the  Senses.  Nos.  10  and  11 — The 
Microscopic  Structure  of  the  Textures  and  Organs.      {Send  for  Special  Circttlar.) 

Maxwell.    ,  Terminologia  Medica  Polyglotta. 
By  Dr.  Theodore  Maxwell.     Octavo.  Cloth,  $3.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality  in  reading  medical 
literature  written  in  a  language  not  their  own.  Each  term  is  usually  given  in  seven  languages, 
viz.  :    English,  French,  German,  Italian,  Spanish,  Russian,  and  Latin. 


28  P.  BLAKISTON'S  SON  &-    CO.' S 

Maylard.     The  Surgery  of  the  AHmentary  Canal. 
By  Alfred  Ernest  Maylard,  m.b.,  b.s.,  Senior  Surgeon  to  the  Victoria  Infirmary, 
Glasgow.     Second  Edition.     97  Illustrations.     Octavo.  Cloth,  $3.00 

Mays'  Theine  in  the  Treatment  of  Neuralgia. 

By  Thomas  J.  Mays,  m.d.      i6mo.  }4  bound,  .50 

Memminger.      Diagnosis  by  the  Urine. 

The  Practical  Examination  of  Urine,  with  Special  Reference  to  Diagnosis.  By 
Allard  Memminger,  m.d.,  Professor  of  Chemistrj'  and  Hygiene  ;  Clinical  Professor 
of  Urinary  Diagnosis  in  the  Medical  College  of  the  State  of  South  Carolina  ;  Visiting 
Physician  in  the  City  Hospital  of  Charleston,  etc.  Second  Edition,  Enlarged  and 
Revised.      24  Illustrations.      i2mo.  Cloth,  $1.00 

Minot.     Embryology. 

A  Laborator\-  Text-Book  of  Embr^-ology.  By  Charles  S.  Minot,  s.d.,  ll.d..  Pro- 
fessor of  Histology  and  Human  Embryology,  Harvard  University  Medical  School. 
Illustrated.  Cloth,  $4.50 

Montgomery.     A  Text-Book  of  Practical  Gynecology. 

By  Edward  E.  Montgomery,  m.d.,  Professor  of  Gynecology  in  Jefferson  Medical 
College,  Philadelphia  ;  Gynecologist  to  the  Jefferson  and  St.  Joseph's  Hospitals,  etc. 
527  Illustrations,   many  of  which    are  from  original  sources.     800  pages.     Octavo. 

Cloth,  $5.00;  Leather,  |6.oo 

"  The  author  has  a  clear  conception  of  his  subject  ;  this,  wiih  his  manner  of  treatment,  intro- 
duces the  reader  to  questions  otherwise  intricate  in  such  a  manner  as  to  make  them  easily  compre- 
hended. His  introduction,  together  wiih  his  comments  on  diagnosis  and  examination  of  the 
patient  are  delightfully  clear  and  instructive.  Therapeutics,  local  and  systematic,  are  clearly  and 
intelligently  discussed." — Brooklyn  Medical  Journal. 

Morris.     Text-Book  of  Anatomy.     Third  Edition.      846   Illustra- 
tions, 167  in  Colors. 

A  Complete  Text-Book.  Edited  by  Henry  Morris,  f.r.c.s.,  Surgeon  to,  and  Lec- 
turer on  Anatomy  at,  Middlesex  Hospital,  assisted  by  Peter  Thompson,  m.d., 
J.  Bland  Sutton,  f.r.c.s.,  J.  H.  Davies-Colley,  f.r.c.s.,  Wm.  J.  Walsham, 
f.r.c.s.,  H.  St.  John  Brooks,  m.d.,  R.  Marcus  Gunn,  f.r.c.s.,  Arthur  Hensman, 
f.r.c.s.,  Frederick  Treves,  f.r.c.s.,  William  Anderson,  f.r.c.s.,  Arthur  Rob- 
inson, M.D.,  M.R.C.S.,  and  Prof.  W.  H.  A.  Jacobson.  One  Handsome  Octavo 
Volume,  with  846  Illustrations,  of  which  267  are  printed  in  Colors.  TJmmb  Index  and 
Colored  Illustrations  in  all  Copies.     Cloth,  $6.00  ;  Leather,  $7.00  ;  Half  Russia,  $8.00 

"  Of  all  the  text-books  of  moderate  size  on  human  anatomy  in  the  English  language,  Morris 
is  undoubtedly  the  most  up-to-date  and  accurate.  .  .  .  For  the  student,  the  surgeon,  or  for  the 
general  practitioner  who  desires  to  review  his  anatomy,  Morris  is  decidedly  the  book  to  buy."  — 
The  Philadelphia  Medical  Jourfial. 

*^*  Morris'  Anatomy  is  now  the  recognized  standard  text-book  in  a  large  number 
of  medical  schools  throughout  the  United  States,  England,  and  Canada.  It  is  in  many 
respects  the  best  book  for  students'  use,  and  in  its  present  edition  is  the  latest  and  best 
illustrated  of  all  books  on  anatomy.  The  revisions  have  been  carefully  made  and 
edited,  several  sections  having  been  almost  entirely  rewritten,  old  illustrations  replaced 
and  new  ones  added,  a  larger  number  being  printed  in  colors. 

Renal  Surgery. 

With  Special  Reference  to  Stone  in  the  Kidney  and  Ureter,  and  to  the  Surgical 
Treatment  of  Calculous  Anuria,  together  with  a  Critical  Examination  of  Sub- 
parietal  Injuries  of  the  Ureter.      Illustrated.      8vo.  Cloth,  $2.00 

Mitchell  and  Gulick.      Mechanotherapy. 

See  Cohen,  Physiologic  Therapeutics,  page  10. 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  29 

Morton  on  Refraction  of  the  Eye. 

Its  Diagnosis  and  the  Correction  of  its  Errors.  With  Chapter  on  Keratoscopy  and 
Test  Types.     By  A.  Morton,  m.b.     Sixth  Edition,  Revised.  Cloth,  |i.oo 

Moullin.     Surgery.     Third  Edition,  by  Hamilton. 

A  Complete  Text-Book.  ByC.  W.  Mansell  Moullin,  m.a.,  m.d.  (Oxon.),  f.r.c.s., 
Surgeon  and  Lecturer  on  Physiology  to  the  London  Hospital ;  formerly  Radcliffe 
Traveling  Fellow  and  Fellow  of  Pembroke  College,  Oxford.  Third  American 
Edition,  Revised  and  Edited  by  the  late  John  B.  Hamilton,  m.d.,  ll.d..  Professor 
of  the  Principles  of  Surgery  and  Clinical  Surgery,  Rush  Medical  College,  Chicago  ; 
Professor  of  Surgery,  Chicago  Polyclinic  ;  Surgeon,  formerly  Supervising  Surgeon- 
General,  U.  S.  Marine  Hospital  Service  ;  Surgeon  to  Presbyterian  Hospital.  600 
Illustrations,  over  200  of  which  are  original,  and  many  of  which  are  printed  in 
Colors.     Octavo.      1250  pages.     Cloth,  $6.00;  Leather,  ^7.00;  Half  Russia,  $8.00 

Enlargement  of  the  Prostate. 

Its   Treatment   and    Radical    Cure.      Illustrated.     Second    Edition,    Enlarged. 
Octavo.  Cloth,  ^1.75 

Inflammation  of  the  Bladder  and  Urinary  Fever. 

Octavo.  Cloth,  $1.50 

Murray.     Rough  Notes  on  Remedies. 

By  Wm.  Murray,  m.d.,  f.r.c.p.  (Lond.),  Consulting  Physician  Newcastle-on-Tyne 
Hospital  for  Sick  Children.      Fourth  Edition,  Enlarged.     Crown  8vo.      Cloth,  $1.25 

Muter.     Practical  and  Analytical  Chemistry. 

By  John  Muter,  f.r.s.,  f.c.s.,  etc.  Second  American  from  the  Eighth  English 
Edition.  Revised  to  meet  the  Requirements  of  American  Medical  and  Pharma- 
ceutical Colleges.      56  Illustrations.  Cloth,  $1.25 

New  Sydenham  Society  Publications. 

From  three  to  six  volumes  published  each  year.     List  of  Volumes  upon  application. 

Per  annum,  $8.00 

Notter.  '  The  Theory  and  Practice  of  Hygiene.     Second  Edition. 

A  Complete  Treatise  by  J.  Lane  Notter,  m.a.,  m.d.,  f.c.s..  Fellow  and  Member 
of  Council  of  the  Sanitary  Institute  of  Great  Britain  ;  Professor  of  Hygiene,  Army 
Medical  School  ;  Examiner  in  Hygiene,  University  of  Cambridge,  etc. ;  and  W.  H. 
HoRROCKS,  M.D.,  B.  Sc.  (Lond.),  Assistant  Professor  of  Hygiene,  Army  Medical 
School,  Netley.  Illustrated  by  15  Lithographic  Plates  and  138  other  Illustrations, 
and  including  m.any  Useful  Tables.  Second  Edition,  Carefully  Revised.  Octavo. 
1085  pages.  Cloth,  $7.00 

Oertel.      Medical  Microscopy. 

A  Guide  to  Diagnosis,  Elementary  Laboratory  Methods,  and  Microscopic  Technic. 
By  T.  E.  Oertel,  m.d.,  Professor  of  Histology,  Pathology,  Bacteriology,  and  Clinical 
Microscopy,  Medical  Department,  University  of  Georgia.     i2mo.      131  Illustrations. 

Cloth,  $2.00 

Oettel.     Practical  Exercises  in  Electro-Chemistry. 

By  Dr.  Felix  Oettel.  Authorized  Translation  by  Edgar  F.  Smith,  m.a..  Professor 
of  Chemistry,  University  of  Pennsylvania.      Illustrated.  Cloth,  .75 

Introduction  to  Electro-Chemical  Experiments. 

Illustrated.     By  same  Author  and  Translator.  Cloth,  .75 


30  P.  BLAKISTON'S  SON  &-   CO.'S 

Ohlemann.     Ocular  Therapeutics  for  Physicians  and  Students. 

By  M.  Ohlemann,  m.d.,  late  Physician  in  the  Ophthalmological  Chnical  Institute, 
Royal  Prussian  University  of  Berlin,  etc.  Translated  and  Edited  by  Charles  A. 
Oliver,  a.m.,  m.d.,  Attending  Surgeon  to  the  Wills  Eye  Hospital ;  Ophthalmic  Surgeon 
to  the  Philadelphia  and  to  the  Presbyterian  Hospitals.      i2mo.  Cloth,  ^1.75 

Ormerod.     Diseases  of  Nervous  System. 

By  J.  A.  Ormerod,  m.d.  (Oxon.),  f.r.c.p..  Physician  to  National  Hospital  for  the 
Paralyzed  and  Epileptic,  London.     66  Wood  Engravings.      i2mo.  Cloth,  $1.00 

Osgood.     The  Winter  and  Its  Dangers. 
By  Hamilton  Osgood,  m.d.  Cloth,  .40 

Ostrom.     Massage  and  the  Original  Swedish  Movements. 

Their  Application  to  Various  Diseases  of  the  Body.  A  Manual  for  Students,  Nurses, 
and  Physicians.  By  Kurre  W.  Ostrom,  from  the  Royal  University  of  Upsala, 
Sweden,  Formerly  Instructor  in  Massage  and  Swedish  Movements  in  the  Hospital  of 
the  University  of  Pennsylvania  and  in  the  Philadelphia  Polyclinic  and  College  for 
Graduates  in  Medicine,  etc.  Fifth  Edition,  Enlarged.  1 1 5  Illustrations,  many  of 
which  were  drawn  especially  for  this  purpose.      i2mo.     Just  Ready.         Cloth,  $1.00 

Packard's  Sea  Air  and  Sea  Bathing. 

By  John  H.  Packard,  m.d.  Cloth,  .40 

Parkes  and  Kenwood.     Hygiene  and  Public  Health. 

A  Practical  Manual.  By  Louis  C.  Parkes,  m.d.,  d.p.h.  (Lond.  Univ.),  Lecturer 
on  Public  Health  at  St.  George's  Hospital;  Medical  Officer  of  Health  and  Public 
Analyst,  Borough  of  Chelsea,  London,  etc.;  and  Henry  Kenwood,  m.b.,  f.c.s., 
Assistant  Professor  of  Public  Health,  University  College,  London,  etc.  Second  Edition, 
Enlarged  and  Revised.     85  Illustrations.      i2mo.     Just  Ready.  Cloth,  $3.00 

*45.*  Upon  the  exhaustion  of  the  fifth  edition  of  what  had  been  known  for  many 
years  as  ' '  Parkes'  Hygiene, ' '  Dr.  Parkes  associated  with  himself  Prof.  Kenwood. 
The  whole  work  was  recast  and  issued  under  this  dual  authorship  as  a  new  book.  This 
edition  is  the  second  printed  under  the  new  arrangement,  but  is  really  the  seventh 
revision. 

"  The  style  is  good ;  dry  facts,  laws,  and  statistics  are  put  in  such  a  way  that  the  reader  does 
not  tire  of  them  and  yet  finds  thera  easy  to  lemember." — University  Medical  Magazine. 

Parsons.     Elementary  Ophthalmic  Optics. 

By  J.  Herbert  Parsons,  m.b.,  m.r.c.s.,  Chnical  Assistant,  Royal  London  Ophthal- 
mic Hospital.     With  Diagrammatic  Illustrations.     Just  Ready.  Cloth,  %i.oo 

Pershing.     The  Diagnosis  of  Nervous  and  Mental  Diseases. 

By  Howell  T.  Pershing,  m.d..  Professor  of  Nervous  and  Mental  Diseases  in  the 
University  of  Denver;  Neurologist  to  St.  Luke's  Hospital;  Consultant  in  Nervous 
and  Mental  Diseases  to  the  Arapahoe  County  Hospital  ;  Member  of  the  American 
Neurological  Association.     With  colored  and  other  Illustrations.  Cloth,  ti.i^ 

Phillips.     Spectacles  and  Eyeglasses. 

Their  Prescription  and  Adjustment.  By  R.  J.  Phillips,  m.d.,  late  Adjunct  Profes- 
sor of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  ;  Ophthalmic  Surgeon,  Presby- 
terian Orphanage.     Third  Edition,  Revised  and  Enlarged.      52  Illustrations.      i2mo. 

Cloth,  $1.00 


MEDICAL  AND   SCIENTIFIC  PLBLICATIONS.  31 

The  Physician's  Visiting  List. 

Published  Annually.     Fifty-Second  Year  (1903)  of  its  Publication. 

Hereafter  all  styles  will  contain  the  interleaf  or  special  memoranda  page,  except 
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REGULAR    EDITION. 

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■>  I  July  to  Dec.  J 

1        f  Tan.  to  Tune  \  \, 
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g^"  This  list  combines  the  several  essential  qualities  of  strength,  compactness, 
durability,  and  convenience.  It  is  made  in  all  sizes  and  styles  to  meet  the  wants  of  all 
physicians.  It  is  not  an  elaborate,  complicated  system  of  keeping  accounts,  but  a 
plain,  simple  record,  that  may  be  kept  with  the  least  expenditure  of  time  and  trouble — 
hence  its  popularity.  A  special  circular,  descriptive  of  contents,  will  be  sent  upon 
application. 

Potter.     A  Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics.    Ninth  Edition,  Enlarged. 

Including  the  Action  of  Medicines,  Special  Therapeutics  of  Disease,  Official  and 
Practical  Pharmacy,  and  Minute  Directions  for  Prescription  Writing,  etc.  Including 
over  650  Prescriptions  and  Formulae.  By  Samuel  O.  L.  Potter,  m.a.,  m.d.,  m.r.c.p. 
(Lond.),  formerly  Professor  of  the  Principles  and  Practice  of  Medicine,  Cooper  Medical 
College,  San  Francisco  ;  Major  and  Brigade  Surgeon,  U.  S.  Vol.  Ninth  Edition, 
Revised  and  Enlarged.  8vo.  Just  Ready. 
With  Thumb  Index  in  each  copy.     Cloth,  $5.00  ;  Leather,  $6.00  ;  Half  Russia,  $7.00 

Compend  of  Anatomy,  including  Visceral  Anatomy. 

Sixth  Edition,    Revised  and  greatly  Enlarged.     With    16   Lithographed  Plates 
and  117  other  Illustrations.     Being  No.  i  f  Quiz- Compeftd  ?  Series. 

Cloth,  .80;  Interleaved  for  Taking  Notes,  $1.00 

Compend   of    Materia   Medica,   Therapeutics,   and    Prescription 

Writing. 

With  Special  Reference  to  the  Physiological  Action  of  Drugs.     Sixth  Revised  and 
Improved  Edition,  with  Index.     Being  No.  6  ?  Quis- Compend  ?■  Seties. 

Cloth,  .80;   Interleaved  for  Taking  Notes,  $1.00 


32  P.  BLAKISTON'S  SON  &-   CO.' S 

Potter.     Speech  and  Its  Defects. 

Considered  Physiologically,  Pathologically,  and  Remedially  ;  being  the  Lea  Prize 
Thesis  of  Jefferson  Medical  College,  1882.     Revised  and  Corrected.         Cloth,  ^i.oo 

Power.     Surgical  Diseases  of  Children 

and  their  Treatment  by  Modern  Methods.  By  D'Arcy  Power,  m.a.,  f.r.c.s. 
(Eng.),  Demonstrator  of  Operative  Surgery,  St.  Bartholomew's  Hospital ;  Surgeon 
to  the  Victoria  Hospital  for  Children.      Illustrated.      i2mo.  Cloth,  $2.50 

Preston.     Hysteria  and  Certain  Allied  Conditions. 

Their  Nature  and  Treatment.  With  Special  Reference  to  the  Application  of  the  Rest 
Cure,  Massage,  Electrotherapy,  Hypnotism,  etc.  By  George  J.  Preston,  m.d., 
Professor  of  Diseases  of  the  Nervous  System,  College  of  Physicians  and  Surgeons, 
Baltimore  ;  Visiting  Physician  to  the  City  Hospital ;  Consulting  Neurologist  to  Bay 
View  Asylum  and  the  Hebrew  Hospital  ;  Member  American  Neurological  Associa- 
tion, etc.     Illustrated.      i2mo.  Cloth,  $2.00 

Pritchard.     Handbook  of  Diseases  of  the  Ear. 

By  Urban  Pritchard,  m.d.,  f.r.c.s..  Professor  of  Aural  Surgery,  King's  College, 
London;  Aural  Surgeon  to  King's  College  Hospital;  Senior  Surgeon  to  the  Royal 
Ear  Hospital,  etc.     Fourth  Edition.     Many  Illustrations  and  Formulae.  In  Press. 

Proctor's  Practical  Pharmacy. 

Lectures  on  Practical  Pharmacy.  By  Barnard  S.  Proctor.  Third  Edition,  Re- 
vised.   With  Elaborate  Tables  of  Chemical  Solubilities,  etc.     Illustrated.    Cloth,  ^3.00 

Reese's  Medical  Jurisprudence  and  Toxicology. 
A  Text-Book  for  Medical  and  Legal  Practitioners  and  Students.  By  John  J.  Reese, 
M.D.,  Editor  of  "Taylor's  Jurisprudence,"  formerly  Professor  of  the  Principles  and 
Practice  of  Medical  Jurisprudence,  including  Toxicology,  in  the  University  of  Pennsyl- 
vania Medical  Department.  Sixth  Edition,  Revised  and  Edited  by  Henry  Leffmann, 
M.D.,  Pathological  Chemist,  Jefferson  Medical  College  Hospital ;  Chemist,  State  Board 
of  Health  ;  Professor  of  Chemistry,  Woman' s  Medical  College  of  Pennsylvania,  etc. 
i2mo.     660  pages.  Cloth,  $3.00;  Leather,  $3.50 

"To  the  student  of  medical  jurisprudence  and  toxicology  it  is  invaluable,  as  it  is  concise, 
clear,  and  thorough  in  every  respect.' ' — TAe  American  Joiirnal  of  the  Medical  Sciences. 

Reeves.     Medical  Microscopy. 

Including  Chapters  on  Bacteriology,  Neoplasms,  Urinary  Examination,  etc.  By 
James  E.  Reeves,  m.d.,  ex-President  American  Public  Health  Association,  etc. 
Numerous  Illustrations,  some  of  which  are  printed  in  Colors.      i2mo.       Cloth,  $2.50 

Regis.     Mental  Medicine. 

A  Practical  Manual.  By  Dr.  E.  Regis,  formerly  Chief  of  Clinique  of  Mental  Dis- 
eases, Faculty  of  Medicine  of  Paris.  Authorized  Translation  by  H.  M.  Bannister, 
M.D.,  late  Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane,  etc. 
With  an  Introduction  by  the  Author.      i2mo.  Cloth,  $2.00 

Richardson.      Long  Life 
and  How  to  Reach  It.     By  J.  G.  Richardson,  formerly  Professor  ot  Hygiene,  Uni- 
versity of  Pennsylvania.  Cloth,  .40 

Rockwood.     Chemical  Analysis. 

Introduction  to  Chemical  Analysis  for  Students  of  Medicine,  Pharmacy,  and  Dentistry. 
By  Elbert  W.  Rockwood,  b.s.,  m.d..  Professor  of  Chemistry,  Toxicology,  and 
Metallurgy  in  the  Colleges  of  Medicine,  Dentistry,  and  Pharmacy,  University  of  Iowa, 
Iowa  City.      Illustrated.  Cloth,  $1.50 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  33 

Richardson's  Mechanical  Dentistry. 
A  Practical  Treatise  on  Mechanical  Dentistry.  By  Joseph  Richardson,  d.d.s. 
Seventh  Edition,  Thoroughly  Revised  and  in  many  parts  Rewritten  by  Geo.  W. 
Warren,  a.m.,  d.d.s.,  Professor  of  Clinical  Dentistry  and  Oral  Surgery;  Chief  of 
the  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery,  Philadelphia.  With  691 
Illustrations.     Octavo.     675  pages.  Cloth,  $5.00 ;  Leather,  $6.00 

Richter's  Inorganic  Chemistry. 
A  Text-Book  for  Students.  By  Prof.  Victor  von  Richter,  University  of  Breslau. 
Fifth  American  from  Tenth  German  Edition  by  Prof.  H.  Klinger,  University  of 
Konigsberg.  Authorized  Translation  by  Edgar  F.  Smith,  m.a.,  ph.d.,  Scd., 
Professor  of  Chemistry,  University  of  Pennsylvania  ;  Member  of  the  Chemical  Society 
of  Berlin,  etc.     With  many  Illustrations  and  a  Colored  Plate.     i2mo.       Cloth,  $1.75 

Organic  Chemistry. 

The  Chemistry  of  the  Carbon  Compounds.  Third  American  Edition,  Translated 
from  Prof.  Anschutz's  Eighth  German  Edition  by  Edgar  F.  Smith,  m.a., 
PH.D.,  Sc.D.,  Professor  of  Chemistry,  University  of  Pennsylvania.  Revised 
and  Enlarged.      Illustrated.      i2mo.     Two  volumes. 

Vol.     I.     Aliphatic  Series.     625  pages.  Cloth,  $3.00 

Vol.  II.     Carbocyclic  and  Heterocyclic  Series.     671  pages.  Cloth,  $3.00 

Roberts.     Gynecological  Pathology. 

Gynecological  Pathology.  By  Charles  Hurbert  Roberts,  m.d.,  f.r.c.s.,  m.r.c.p., 
Physician  Queen  Charlotte's  Lying-in  Hospital  and  to  the  Samaritan  Hospital  for 
Women  ;  Demonstrator  of  Practical  Midwifery  and  Diseases  of  Women,  and  House 
Surgeon  St.  Bartholomew's  Hospital,  London.  Elaborately  Illustrated  with 
127  Full-Page  Plates  containing  151  Figures,  several  being  printed  in  Colors. 
Octavo.  Extra  Cloth,  Gilt  Top,  $6.00 

Robinson.      Latin  Grammar  of  Pharmacy  and  Medicine. 

By  D.  H.  Robinson,  ph.d.,  Professor  of  Latin  Language  and  Literature,  University 
of   Kansas.     Introduction    by    L.    E.    Sayre,    ph.g..    Professor    of  Pharmacy   and 
Dean  of  the  Department    of  Pharmacy  in  University  of   Kansas.     Third  Edition, 
Revised  with  the  help  of  Prof.   L.   E.  Sayre,  of  University  of  Kansas,  and  Dr. 
Charles  Rice,  of  the  College  of  Pharmacy  of  the  City  of  New  York.     Cloth,  $1.75 
"  This  method  of  preparing  medical  students  and  pharmacists  for  a  practical  use  of  the  lan- 
guage is  in  every  way  to  be  commended.     .     .     .     Pharmacists  should  know  enough  to  read  pre- 
scriptions readily  and  understandingly." — Johns  Hopkins  Hospital  Bulletin. 

Rosenau.     Disinfection  and  Disinfectants. 

A  Practical  Guide  for  Sanitarians,  Health  and  Quarantine  Officers.  By  M.  J.  Rose- 
nau, M.D.,  Director  of  the  Hygienic  Laboratory  and  PassedAssistant  Surgeon,  U.  S  . 
Marine  Hospital  Service,  Washington,  D.  C.     Illustrated.  Cloth,  ^2.00 

Sayre.     Organic  Materia  Medica  and  Pharmacognosy. 

An  Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vegetable  and 
Animal  Drugs.  Comprising  the  Botanical  and  Physical  Characteristics,  Source, 
Constituents,  Pharmacopoeial  Preparations  ;  Insects  Injurious  to  Drugs,  and  Phar- 
macal  Botany.  By  L.  E.  Sayre,  b.s.,  ph.m.,  Dean  of  the  School  of  Pharmacy  and 
Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Kansas  ;  Member 
Committee  of  Revision  of  the  United  States  Pharmacopoeia,  etc.  With  Sections  on 
Histology  and  Microtechnique  by  William  C.  Stevens,  Professor  of  Botany  in  the 
University  of  Kansas.  Second  Edition,  Revised  and  Enlarged.  With  374  Illustra- 
tions, the  majority  of  which  are  from  Original  Drawings.     8vo.  Cloth,  $\.^o 

Schamberg.     Compend  of  Diseases  of  the  Skin. 

By  Jay  F.  Schamberg,  Professor  of  Diseases  of  the  Skin,  Philadelphia  Polyclinic  ; 
Fellow  of  the  College  of  Physicians  of  Philadelphia  ;  Quiz-Master  at  University  of 
Pennsylvania.  Third  Edition,  Revised  and  Enlarged.  106  Illustrations.  ?  Quiz- 
Compend?  Series,  No.  16.  Cloth,  .80;    Interleaved,  $1.00 


34  P.   BLAKISTON' S  SON  &-    CO.' S 

Scheube.     Diseases  of  Warm  Countries. 

A  Handbook  for  Medical  Men  by  Dr.  B.  Scheube,  State  Physician  and  Sanitary 
Adviser,  Greiz  ;  late  Professor  at  the  Medical  School  in  Kioto,  Japan.  Translated 
from  the  German  by  Pauline  Falcke  and  edited  by  James  Cantlie,  m.a.,  m.b., 
F.R.C.S.,  Lecturer  at  the  London  School  of  Tropical  Medicine  ;  Surgeon  to  the  Sea- 
men's Hospital  Society  Albert  Dock  Hospital,  London  ;  Consulting  Surgeon  Alice 
Memorial  Hospital,  Hong  Kong,  etc.,  with  Addenda  on  Yellow  Fever  by  the  Editor 
and  on  Malaria  by  C.  W.  Daniels,  m.r.c.s.  With  19  Plates  (containing  many 
figures,  29  of  which  are  in  colors)  and  38  other  Illustrations  together  with  5  Colored 
Maps.     Second  Revised  Edition.     Large  Octavo.     Just  Ready.  Cloth,  $8.00 

Schofield.     The  Force  of  Mind, 

or  The  Mental  Factor  in  Medicine.     By  A.  T.  Schofield,  m.d.  Cloth,  $2.00 

Schreiner.     Diet  List. 

Arranged  in  the  Form  of  a  Chart  on  which  Articles  of  Diet  can  be  Indicated  for  any 
Disease.  By  E.  R.  Schreiner,  m.d.  Put  up  in  Pads  of  50  with  Pamphlet  of  Speci- 
men Dietaries.  Per  Pad,  .75 

Scott.     The  Urine  :   Its  Chemical  and  Microscopical  Examination. 
By  Lindley  Marcroft  Scott,  m.a.,  m.d.,  etc.     With  41  Colored  Plates  and  other 
Illustrations.     Quarto.  Cloth,  $5.00 

Scoville.     The  Art  of  Compounding.     Second  Edition. 

A  Text-Book  for  Students  and  a  Reference  Book  for  Pharmacists.  By  Wilbur  L. 
Scoville,  ph.g..  Professor  of  Applied  Pharmacy  and  Director  of  the  Pharmaceutical 
Laboratory  in  the  Massachusetts  College  of  Pharmacy.  Second  Edition,  Enlarged 
and  Improved.  Cloth,  $2.50;  Sheep,  $3.50 

Self-Examination  for  Medical  Students. 

3500  Questions  on  Medical  Subjects,  with  the  proper  References  to  Standard  Books 
in  which  replies  may  be  found,  and  including  Complete  Sets  of  Questions  from  two 
recent  State  Board  Examinations  of  Penn.,  111.,  and  N.  Y.     64mo.     Paper,  10  cents. 

Smith.     Abdominal  Surgery.     Sixth  Edition. 

Being  a  Systematic  Description  of  all  the  Principal  Operations.  By  J.  Greig  Smith, 
M.A.,  F.R.S.E.,  Surgeon  to  British  Royal  Infirmary.  224  Illustrations.  Sixth  Edition, 
Enlarged  and  Thoroughly  Revised  by  James  Swain,  m.d.  (Lond.),  f.r.c.s.,  Pro- 
fessor of  Surgery,  University  College,  Bristol,  etc.     Two  vols.     8vo.      Cloth,  $10.00 

Smith.     Bacteriology. 

Lessons  and  Laboratory  Exercises  in  Bacteriology.  An  Outline  of  Technical  Methods 
Introductory  to  the  Systematic  Study  and  Identification  of  Bacteria.  By  Allen  I. 
Smith,  m.d..  Professor  of  Pathology  in  the  University  of  Texas.  68  Illustrations. 
Interleaved.     Octavo.  Cloth,  $1.50 

Smith.     Electro-Chemical  Analysis. 

By  Edgar  F.  Smith,  m.a.,  ph.d.,  Scd.,  Professor  of  Chemistry,  University  of 
Pennsylvania.     Third    Edition,    Revised   and    Enlarged.      39    Illustrations.      i2mo. 

Cloth,  $i.5o> 
*^*  This  book  has  been  translated  and  published  in  both  Germany  and  France. 

Smith  and  Keller.     Experiments. 

Arranged  for  Students  in  General  Chemistry.  By  Edgar  F.  Smith,  m.a.,  ph.d., 
Sc.D.,  Professor  of  Chemistry,  University  of  Pennsylvania,  and  Dr.  H.  F.  Keller, 
Professor  of  Chemistry,  Philadelphia  High  School.  Fourth  Revised  Edition.  8vo. 
Illustrated.  Cloth,  .60 

Smith.     Dental  Metallurgy. 

A  Manual.  By  Ernest  A.  Smith,  f.c.s..  Assistant  Instructor  in  Metallurgy,  Royal 
College  of  Science,  London.      Illustrated.     Second  Edition.  Cloth,  «;2.oO' 

Smith.     Wasting  Diseases  of  Infants  and  Children. 

By  Eustace  Smith,  m.d.,  f.r.c.p.,  Physician  to  the  East  London  Hospital  for 
Children,  etc.     Sixth  Edition,  Revised.  Cloth,  $2.00 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  35 

Starling.      Elements  of  Human  Physiology. 

By  Ernest  H.  Starling,  m.d.  (Lond.),  m.r.c.p.,  Joint  Lecturer  on  Physiology  at 
Guy's  Hospital,  London,  etc.     With  loo  lUus.      i2mo.     437  pages.        Cloth,  $1.00 

Starr.     The  Digestive  Organs  in  Childhood. 

The  Diseases  of  the  Digestive  Organs  in  Infancy  and  Childhood,  with  Chapters  on  the 
Investigation  of  Disease,  The  Management  of  Children,  Massage,  etc.  By  Louis 
Starr,  m.d.,  late  Clinical  Professor  of  Diseases  of  Children  in  the  Hospital  of  the 
University  of  Pennsylvania;  Physician  to  the  Children's  Hospital,  Philadelphia. 
Third  Edition,  Revised  and  Enlarged.      Illustrated.     Octavo.  Cloth,  $3.00 

The  Hygiene  of  the  Nursery. 

Including  the  General  Regimen  and  Feeding  of  Infants  and  Children,  and  the 
Domestic  Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc. 
Sixth  Edition,  Enlarged.      25  Illustrations.      i2mo.  Cloth,  ^i.oo 

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Stearns.      Lectures  on  Mental  Diseases. 

By  Henry  Putnam  Stearns,  m.d.,  Physician-Superintendent  at  the  Hartford  Retreat ; 
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Stevenson  and  Murphy.     A  Treatise  on  Hygiene. 

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Chemistry  and  Medical  Jurisprudence  at  Guy's  Hospital,  London,  and  Shirley  F. 

Murphy,   Medical  Officer  of  Health  to  the  County  of   London.     In  three  octavo 

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PH.G.,  late  Quiz-Master  in  Chemistry  and  Theoretical  Pharmacy,  Philadelphia  College 
of  Pharmacy  ;  Lecturer  on  Pharmacology,  Jefferson  Medical  College.  Fifth  Edition. 
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Series.  Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  $1.00 

Stirling.     Outlines  of  Practical  Physiology. 

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Outlines  of  Practical  Histology. 

368  Illustrations.  Second  Edition,  Revised  and  Enlarged.  With  new  Illustra- 
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36  P.  BLAKISTON'S  SON  &-   CO.' S 

Stohr.        Text-Book    of    Histology,    Including    the    Microscopical 
Technic.     379  Illustrations.     New  Edition. 

By  Dr.  Philip  Stohr,  Professor  of  Anatomy  at  University  of  Wiirzburg.     Author- 
ized Translation  by  Emma  L.  Bilstein,  m.d.,  formerly  Demonstrator  of  Histology, 
Woman's    Medical  College    of  Penna.     Edited,   with  Additions,   by   Dr.  Alfred 
ScHAPER,  Professor  of  Anatomy,  University  of  Breslau;  formerly  Demonstrator  of 
Histology,  Harvard  Medical  School,  Boston.    Fourth  American  based  upon  the  Ninth 
German  Edition,  Enlarged  and  Revised.     379  Illustrations.     Octavo.         Cloth,  $3.00 
"This  edition  of  an  already  well-known  student's  manual  requires  little  but  favorable  com- 
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work's  position  more  secure.     The  book  is  not  only  a  useful  one  for  the  student,  but  makes  a  very 
good  work  of  reference  for  its  subject,  and  is  thus  entitled  to  a  place  upon  the  shelves  of  the  prac- 
titioner."—  T^£  Medical  Record,  New  York. 

Sturgis.     Manual  of  Venereal  Diseases.     Seventh  Edition. 

By  F.  R.  Sturgis,  m.d.,  Sometime  Clinical  Professor  of  Venereal  Diseases  in  the 
Medical  Department  of  the  University  of  the  City  of  New  York  ;  formerly  one  of 
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Seventh  Edition,  Revised  and  in  part  Rewritten  by  F.  R.  Sturgis,  m.d.,  and  Follen 
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versity Medical  College  ;  Genito-Urinary  Out-Patient  Surgeon  to  Bellevue  Hospital ; 
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Cloth,  $1.25 

Sutton's  Volumetric  Analysis. 

A  Systematic  Handbook  for  the  Quantitative  Estimation  of  Chemical  Substances  by 
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With  116  Illustrations.      8vo.  Cloth,  $5.00 

Swanzy.     Diseases  of  the  Eye  and  their  Treatment. 

A  Handbook  for  Physicians  and  Students.  By  Henry  R.  Swanzy,  a.m.,  m.b., 
F.R.C.S.I.,  Examiner  in  Ophthalmology,  University  of  Dublin  ;  Surgeon  to  the  National 
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practitioner." — Chicago  Aledical  Recorder. 

Symonds.      Manual  of  Chemistry 

for  Medical  Students.  By  Brandreth  Symonds,  a.m.,  m.d..  Assistant  Physician 
Roosevelt  Hospital,  Out-Patient  Department,  New  York.     Second  Edition.      i2mo. 

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Taft.     Index  of  Dental  Periodical  Literature. 

By  Jonathan  Taft,  d.d.s.     8vo.  Cloth,  $2.00 

Tanner's  Memoranda  of  Poisons 

and  their  Antidotes  and  Tests.  By  Thos.  Hawkes  Tanner,  m.d.  Ninth  Edition, 
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MEDICAL   AND   SCIENTIFIC  PUBLICATIONS.  37 

Tavera.      Medicinal  Plants  of  the  Philippines. 

By  T.  H.  Pardo  de  Tavera,  Doctor  of  Medicine  in  Faculty  of  Paris  ;  Scientific 
Commissioner  S.M.  in  Philippine  Islands,  etc.  Translated  and  Revised  by  Jerome 
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Cloth,  $2.00 

Taylor.     Practice  of  Medicine. 

By  Frederick  Tavlor,  m.d..  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London  ;  Physician  to  Evelina  Hospital  for  Sick  Children.  Sixth  Edition, 
Revised.  Cloth,  $4.00 

Taylor  and  Wells.     Diseases  of  Children.     Illustrated. 

A  Manual  for  Students  and  Physicians.  By  John  Madison  Taylor,  a.m.,  m.d., 
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phia Hospital ;  Assistant  Physician  to  the  Children's  Hospital  ;  Consulting  Physician 
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Mt.  Sinai  Hospital.  With  Numerous  Illustrations.  Second  Edition,  Revised  and 
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Temperature  Charts 

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(The  Shadow  Test)  in  the  Determination  of  Refraction  at  One  Meter  Distance  with 
the  Plane  Mirror.  By  James  Thorington,  a.m.,  m.d.,  Professor  of  Diseases  of  the 
Eye  in  the  Philadelphia  Polyclinic  ;  Ophthalmologist  to  the  Elwyn,  Vineland,  and 
New  Jersey  State  Training  Schools  for  Feeble-minded  Children  ;  Lecturer  on  the 
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Refraction  and  How  to  Refract.     Second  Edition. 

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Synopsis  of  Contents.— I.  Optics.  II.  The  Eye  ;  The  Standard  Eye  ; 
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Vision  ;  Size  of  Retinal  Image,  Accommodation  ;  Mechanism  of  Accommoda- 
tion ;  Far  and  Near  Point  ;  Determination  of  Distant  Vision  and  Near  Point ; 
Amplitude  of  Accommodation  ;  Convergence  ;  Angle  Gamma  ;  Angle  Alpha. 
III.  Ophthalmoscope;  Direct  and  Indirect  Method.  IV.  Emmetropia  ;  Hyper- 
opia ;  Myopia.  V.  Astigmatism  or  Curvature  Ametropia  ;  Tests  for  Astigma- 
tism. VI.  Retinoscopy.  VII.  Muscles.  VIII.  Cycloplegics  ;  Cycloplegia  ; 
Asthenopia ;  Examination  of  the  Eyes.  IX.  How  to  Refract.  X.  Applied 
Refraction.  XL  Presbyopia  ;  Aphakia ;  Anisometropia  ;  Spectacles.  XII. 
Lenses  ;  Spectacle  and  Eye  Glass  Frames  ;  How  to  Take  Measurements  for 
Them  and  How  They  Should  be  Fitted.     Index. 


38  P.  BLAKISTON'S  SON  &-   CO.'S 

Thorne.     The   Schott  Methods  of  the  Treatment  of  Chronic  Dis- 
eases of  the  Heart. 

With  an  Account  of  the  Nauheim  Baths  and  of  the  Therapeutic  Exercises.  By  W. 
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Fourth  Edition,  Revised  and  Enlarged.     Octavo.  Cloth,  ^2.00 

Thresh.     Water  and  Water  Supplies. 

By  John  C.  Thresh,  d.sc.  (Lond.),  m.d.,  d.p.h.  (Cambridge),  Medical  Officer  of 
Health  to  the  Essex  County  Council ;  Lecturer  on  Public  Health,  King's  College, 
London  ;  Fellow  of  the  Institute  of  Chemistry ;  Member  Society  Public  Analysts, 
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Tissier.     Pneumatotherapy  and  Inhalation  Methods. 
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Tomes'  Dental  Anatomy. 

A  Manual  of  Dental  Anatomy,  Human  and  Comparative.  By  C.  S.  Tomes,  d.d.s. 
263  Illustrations.     Fifth  Edition.  i2mo.  Cloth,  $4.00 

Dental  Surgery. 
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oughly Revised  by  C.  S.  Tomes,  d.d.s.  With  289  Illustrations.      i2mo.     717 
pages.  Cloth,  $4.00 

Traube.     Physico-Chemical  Methods. 

By  Dr.  J.  Traube,  Privatdocent  in  the  Technical  High  School  of  Berlin.  Author- 
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Treves.     German-English  Medical  Dictionary. 

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Physical  Education  :   Its  Effects,  Value,  Methods,  etc.     8vo. 

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Tuke.     Dictionary  of  Psychological  Medicine. 

Giving  the  Definition,  Etymology,  and  Synonyms  of  the  Terms  used  in  Medical  Psy- 
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Turnbull's  Artificial  Anesthesia. 

A  Manual  of  Anesthetic  Agents  in  the  Treatment  of  Diseases,  also  their  Employment 
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Fourth  Edition,  Revised.      54  Illustrations.      i2mo.  Cloth,  $2.50 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  39 

Tyson.     The  Practice  of  Medicine.     Second  Edition. 

A  Text-Book  for  Physicians  and  Students,  with  Special  Reference  to  Diagnosis  and 
Treatment.  By  James  Tyson,  m.d.,  Professor  of  Medicine  in  the  University  of 
Pennsylvania;  Physician  to  the  University  and  to  the  Philadelphia  Hospitals,  etc. 
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Guide  to  the  Examination  of  Urine.     Tenth  Edition. 

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Handbook  of  Physical  Diagnosis. 

Fourth  Edition,  Revised  and  Enlarged.  With  two  Colored  Plates  and  55  other 
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Cell  Doctrine. 

Its  History  and  Present  State.     Second  Edition.  Cloth,  $1.50 

United  States  Pharmacopoeia,  1890. 

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40  P.  BLAKISTON'S  SON  &-   CO.' S 

Ulzer  and  Fraenkel.  Introduction  to  Chemical-Technical  Analysis. 
By  Prof.  F.  Ulzer  and  Dr.  A.  Fraenkel,  Directors  of  the  Testing  Laboratory  of 
the  Royal  Technological  Museum,  Vienna.  Authorized  Translation  by  Hermann 
Fleck,  nat.sc.d..  Instructor  in  Chemistry  and  Chemical  Technical  Analysis  in  the 
John  Harrison  Laboratory  of  Chemistry,  University  of  Pennsylvania,  with  an 
Appendix  by  the  Translator  relating  to  Food  Stuffs,  Asphaltum,  and  Paint.  12  Illus- 
trations.    8vo.  Cloth,  $1.25 

Van  Niiys  on  the  Urine. 

Chemical  Analysis  of  Healthy  and  Diseased  Urine,  Qualitative  and  Quantitative.  By 
T.  C.  Van  Nuys.     39  Illustrations.     Octavo.  Cloth,  $1.00 

Van  Harlingen  on  Skin  Diseases. 

A  Practical  Manual  of  Diagnosis  and  Treatment,  with  Special  Reference  to  Differential 
Diagnosis.  By  Arthur  Van  Harlingen,  m.d..  Emeritus  Professor  of  Diseases  of 
the  Skin  in  the  Philadelphia  Polyclinic  ;  Dermatologist  to  the  Children's  Hospital. 
Third  Edition,  Revised  and  Enlarged.  With  Formulae  and  Illustrations,  several  being 
in  Colors.      580  pages.  Cloth,  $2.75 

"  As  would  naturally  be  expected  from  the  author,  his  views  are  sound,  his  information 

extensive,  and  in  matters  of  practical  detail  the  hand  of  the  experienced  physician  is  everywhere 

visible. ' '  —  The  Medical  Neivs. 

Virchow's  Post-mortem  Examinations. 

A  Description  and  Explanation  of  the  Method  of  Performing  them  in  the  Dead- 
House  of  the  Berlin  Charite  Hospital,  with  Especial  Reference  to  Medico-Legal 
Practice.  By  Professor  Virchow.  Translated  by  Dr.  T.  P.  Smith.  Illustrated. 
Third  Edition.  Cloth,  .75 

Voswinkel.     Surgical  Nursing. 

A  Manual  for  Nurses.  By  Bertha  M.  Voswinkel,  Graduate  Episcopal  Hospital, 
Philadelphia;  late  Nurse-in-Charge  Children's  Hospital,  Columbus,  O.  Second 
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Walker.     Students'  Aid  in  Ophthalmology. 

By  Gertrude  A.  Walker,  a.b.,  m.d.,  Chnical  Instructor  in  Diseases  of  the  Eye  at 
Woman's  Medical  College  of  Pennsylvania.  40  Illustrations  and  Colored  Plate. 
i2mo.  Cloth,  $1.50 

Walsham.     Surgery  :    Its  Theory  and  Practice.     Seventh  Edition. 
For  Students  and  Physicians.     By  Wm.  J.  Walsham,  m.d.,  f.r.c.s..   Senior  Assist- 
ant Surgeon  to,  and  Demonstrator  of  Practical  Surgery  in,  St.  Bartholomew's  Hospital  ; 
Surgeon  to  Metropolitan  Free  Hospital,  London.     Seventh  Edition,  Revised  and  En- 
larged by  100  pages.     With  483  Illustrations  and  28  Skiagrams.  Cloth,  $3.50 

Warren.     Compend  of  Dental  Pathology  and  Dental  Medicine. 

Containing  all  the  most  Noteworthy  Points  of  Interest  to  the  Dental  Student  and  a 
Chapter  on  Emergencies.  By  George  W.  Warren,  d.d.s..  Professor  of  Chnical 
Dentistry  and  Oral  Surgery  ;  Chnical  Chief,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  Third  Edition,  Enlarged.  Illustrated.  Being  No.  13  ?  Quiz- Com- 
pend f  Series.      i2mo.  Cloth,  .80  ;  Interleaved  for  the  Addition  of  Notes,  ^i.oo 

Dental  Prosthesis  and  Metallurgy. 

129  Illustrations.  Cloth,  $1.25 

Weber     and     Hinsdale.       CHmatology — Health    Resorts — Mineral 
Springs. 
See  Cohen,  Physiologic  Therapeutics,  page  10. 


MEDICAL  AND   SCIENTIFIC  PUBLICATIONS.  41 

Wells.     Compend  of  Gynecology. 

By  Wm.  H.  Wells,  m.d.,  Demonstrator  of  Clinical  Obstetrics,  Jefiferson  Medical 
College,  Philadelphia  ;  Chief  Gynecologist  Mt.  Sinai  Hospital  ;  Fellow  of  the  College 
of  Physicians  of  Philadelphia.  Third  Edition,  Revised.  140  Illustrations.  Being 
No.  1  ?Quis- Compend?  Series.      i2mo.         Cloth,  .80;  Interleaved  for  Notes,  $1.00 

Wethered.     Medical  Microscopy. 

A  Guide  to  the  Use  of  the  Microscope  in  Practical  Medicine.  By  Frank  J.  Weth- 
ered, M.D.,  M.R.C.P.,  Demonstrator  of  Practical  Medicine,  Middlesex  Hospital  Med- 
ical School  ;  Assistant  Physician,  late  Pathologist,  City  of  London  Hospital  for 
Diseases  of  the  Chest,  etc.  With  a  Colored  Plate  and  loi  Illustrations.  406  pages. 
i2mo.  Cloth,  $2.00 

Weyl.     Sanitary  Relations  of  the  Coal-Tar  Colors. 

By  Theodore  Weyl.  Authorized  Translation  by  Henry  Leffmann,  m.d.,  ph.d. 
i2mo.  Cloth,  $1.25 

Whitacre.     Laboratory  Text-Book  of  Pathology. 

By  Horace  J.  Whitacre,  m.d..  Demonstrator  of  Pathology,  Medical  College  of 
Ohio,  Cincinnati.  Illustrated  with  121  Original  Drawings  and  Microphotographs. 
8vo.  Cloth,   ^1.50 

White.     The  Mouth  and  Teeth.     Illustrated. 

By  J.  W.  White,  m.d.,  d.d.s.  Cloth,  .40 

White  and  Wilcox.     Materia  Medica,  Pharmacy,  Pharmacology,  and 
Therapeutics.     Fifth  Edition. 

A  Handbook  for  Students.  By  W.  Hale  White,  m.d.,  f.r.c.p.,  etc.,  Physician  to, 
and  Lecturer  on  Materia  Medica  and  Therapeutics,  Guy's  Hospital;  Examiner  in 
Materia  Medica  to  the  Conjoint  Board,  etc.  Fifth  American  Edition,  Revised  by 
Reynold  W.  Wilcox,  m.a.,  m.d.,  ll.d..  Professor  of  Clinical  Medicine  and  Thera- 
peutics at  the  New  York  Post-Graduate  Medical  School  and  Hospital  ;  Visiting  Phy- 
sician, St.  Mark's  Hospital  ;  Assistant  Visiting  Physician,  Bellevue  Hospital.  En- 
larged and  Improved.      i2mo.  Cloth,  $3.00;  Leather,  ^3.50 

Williams.      Manual  of  Bacteriology.     Second  Edition. 

By  Herbert  U.  Williams,  m.d..  Professor  of  Pathology  and  Bacteriology,  Medical 
Department,  University  of  Buffalo.  Second  Edition,  Revised  and  Enlarged.  90 
Illustrations.      i2mo.      290  pages.  Cloth,  ^1.50 

Wilson.     Handbook  of  Hygiene  and  Sanitary  Science. 

By  George  Wilson,  m.a.,  m.d.,  f.r.s.e..  Medical  Officer  of  Health  for  Mid-War- 
wickshire, England.    With  Illustrations.    Eighth  Edition.     i2mo.  Cloth,  $3.00 

Wilson.     The  Summer  and  its  Diseases. 

By  James  C.  Wilson,  m.d..  Professor  of  the  Practice  of  Medicine  and  Clinical 
Medicine,  Jefferson  Medical  College,  Philadelphia.  Cloth,  .40 

Wilson.     System  of  Human  Anatomy. 

Eleventh  Revised  Edition,  Edited  by  Henry  Edward  Clark,  m.d.,  m.r.c.s.  492 
Illustrations,  26  Colored  Plates,  and  a  Glossary  of  Terms.      i2mo.  Cloth,  #5.00 

Winckel.     Text-Book  of  Obstetrics. 

Including  jthe  Pathology  and  Therapeutics  of  the  Puerperal  State.  By  Dr.  F. 
Winckel,  Professor  of  Gynecology,  Royal  University  Clinic  for  Women  in  Munich. 
Authorized  Translation  by  J.  Clifton  Edgar,  a.m.,  m.d.,  Professor  of  Obstetrics 
and  Clinical  Midwifery,  Cornell  University  Medical  Department,  New  York.  190 
Illustrations.     Octavo.  Ckith,  #5.00;  Leather,  $6.00 


42 


P.  BLAKISTON'S  SON  &-   CO: S  PLBLICATIONS. 


Winternitz.     Hydrotherapy — Thermotherapy — Balneology. 

See  Cohen,  Physiologic  Therapeutics,  page  lo. 

Wood.     Brain  Work  and  Overwork. 

By  H.  C.  Wood,  CHnical  Professor  of  Nervous  Diseases,  University  of  Pennsylvania, 
i2mo.  Cloth,  .40 

Woody.     Essentials  of  Medical  and  Clinical  Chemistry. 

With  Laboratory  Exercises.  By  Samuel  E.  Woody,  a.m.,  m.d..  Professor  of  Chem- 
istry and  Diseases  of  Children  in  the  Medical  Department,  Kentucky  University, 
Louisville.     Fourth  Edition,  Revised  and  Enlarged.     Illustrated.    i2mo.    Cloth,  $1.50 

"  The  fact  that  Prof.  Woody's  little  book  has  reached  a  third  edition  in  such  a  short  time  is 
sufficient  proof  of  its  usefulness  for,  and  demand  by,  the  medical  student.  The  selection  of  the 
material  and  its  plan  of  presentation,  resulting  from  the  author's  large  experience  as  a  practitioner 
and  teacher  of  medical  chemistry,  is  well  intended  to  offer  to  the  student  that  which  is  really  essen- 
tial for  his  limited  college  course,  and,  it  is  to  be  hoped,  a  basis  for  further  instruction  in  the  impor- 
tant branch  of  medical  science." — The  American  Jotirnal  of  Medical  Sciences,  Philadelphia. 

Wright.     Ophthalmology.     New  Edition.      117  Illustrations. 

A  Text-Book  by  John  W.  Wright,  a.m.,  m.d..  Professor  of  Ophthalmology  and 
CHnical  Ophthalmology  in  Ohio  Medical  University  ;  Ophthalmologist  to  the  Protest- 
ant and  University  Hospitals,  etc.  Second  Edition,  Revised,  Rewritten,  and  Enlarged. 
With  many  new  Illustrations.  Cloth,  $3.00 


THE  STANDARD  TEXT=BOOK 


NATOMY 


New  Edition 


Third  Revised  Edition,  Enlarged  and  Improved 

846  Illustrations,  of  which  267  are  Gilored 

Octavo.     i328  Pages.     Qoth,  $6.00;  Leather,  $7.00 

"  Morris'  Anatomy"  was  published  at  a  time  when  methods  of  teaching, 
the  art  of  engraving,  a7td  distijtcl  advance  in  anatomical  illustration 
made  desirable  a  7iew  and  modern  text-book.  The  rapid  sale  of  the  first 
edition,  its  immediate  adoption  as  a  text-book  by  a  large  number  of  medi- 
cal schools,  and  its  purchase  by  physicians  and  surgeons  proved  its  value 
and  made  it  from  the  day  of  publication  a  standard  authority. 

In  making  this  new  edition  the  editors  and  publishers  have  used  every 
endeavor  to  enhance  its  value.  The  text  has  been  thoroughly  revised  and 
in  many  parts  rewritten ;  the  editor  has  devoted  himself  to  the  task  of 
making  it  a  harmonious  whole ;  many  new  illustrations  have  replaced 
those  used  in  the  first  edition,  and  a  large  number  have  been  printed  in 
colors,  while  the  typographical  appearance  has  been  improved  in  several 
particulars. 

The  illustrations,  in  correctness  and  excellence  of  execution,  are  equaled 
by  no  similar  treatise;  about  ^1000  having  been  expended  on  new  and 
improved  blocks  for  this  edition  alone. 

"  The  evergrowing  popularity  of  the  book  with  teachers  and  students  is  an  index  of  its  value, 
and  it  may  safely  be  recommended  to  all  interested." — Medical  Record,  New  York. 

"  Of  all  the  text-books  of  moderate  size  on  human  anatomy  in  the  English  language,  Morris 
is  undoubtedly  the  most  up-to-date  and  accurate." — Philadelphia  Medical  Journal. 

%*  CIRCULAR  WITH  SAMPLE  PAGES  AND  ILLUSTRATIONS  FREE. 


THUMB 
INDEX 
IN  EACH 

copy 


From  the  Southern  Clinic. 

'\  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully  meets  our  approval  as  thes« 
?  Quiz-Compends  ?.  They  are  well  arranged,  full,  and  concise,  and  are  really  the  best  line  of  text- 
books  that  could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?QUIZ=COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 

Price  of  each,  Cloth,  .80.       Interleaved  for  taking  Notes,  Sl.OO. 

g^^These  Compends  are  based  on  the  most  popular  text-books  and  the  lectures  of  prominent 
professors,  and  are  kept  constantly  revised,  so  that  they  may  thoroughly  represent  the  present  state 
of  the  subject  upon  which  they  treat.  The  authors  have  had  large  experience  as  Quiz-Masters 
and  attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students.  They  are  arranged 
in  the  most  approved  form,  thorough  and  concise,  containing  over  900  illustrations,  inserted 
wherever  they  could  be  used  to  advantage.  Can  be  used  by  students  of  atty  college,  and  contain 
information  nowhere  else  collected  in  such  a  condensed  practical  shape. 

No.  I.  HUMAN  ANATOMY.  Sixth  Revised  and  Enlarged  Edition.  Including  Vis- 
ceral Anatomy.  Can  be  used  with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and 
16  Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory  Tables,  etc.  By  Samuel 
O.  L.  Potter,  m.d.,  formerly  Professor  of  the  Practice  of  Medicine,  Cooper  Medical  College, 
San  Francisco;   Major  and  Brigade  Surgeon,  U.  S.  Vol. 

No.  2.  PRACTICE  OF  MEDICINE.  Part  I.  Sixth  Edition,  Revised,  Enlarged,  and 
Improved.  By  Dan'l  E.  Hughes,  m.d..  Physician -in-Chief,  Philadelphia  Hospital;  late 
Demonstrator  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

No.  3.  PRACTICE  OF  MEDICINE.  Part  II.  Sixth  Edition,  Revised,  Enlarged,  and 
Improved.     Same  author  as  No.  2. 

No.  4.  PHYSIOLOGY.  Eleventh  Edition,  with  new  Illustrations.  Enlarged  and  Revised. 
By  A.  P.  Brubaker,  m.d..  Professor  of  Physiology  in  the  Pennsylvania  College  of  Dental 
Surgery;  Adjunct  Professor  of  Physiology,  Jefferson  Medical  College,  Philadelphia. 

No.  5.  OBSTETRICS.  Seventh  Edition.  By  Henry  G.  Landis,  m.d.  Revised  and 
Edited  by  Wm.  H.  Wells,  m.d..  Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical 
College,  Philadelphia.     Enlarged.     52  Illustrations. 

No.  6.  MATERIA  MEDIC  A,  THERAPEUTICS,  AND  PRESCRIPTION 
WRITING.     Sixth  Revised  Edition.     Same  author  as  No.  i. 

No.  7.  GYNECOLOGY.  Third  Edition.  By  Wm.  H.  Wells,  m.d..  Demonstrator  of 
Clinical  Obstetrics,  Jefferson  Medical  College,  Philadelphia.      140  Illustrations. 

No.  8.  DISEASES  OF  THE  EYE  AND  REFRACTION.  Second  Edition.  Includ- 
ing Treatment  and  Surgery  and  a  Section  on  Local  Therapeutics.  By  George  M.  Gould, 
m.d.,  Editor  Philadelphia  Medical  Journal,  and  W.  L.  Pyle,  M.d.  ,  Assistant  Surgeon,  Wills 
Eye  Hospital.     With  Formulae,  Glossary,  several  useful  Tables,  and  109  Illustrations. 

No.  9.  SURGERY,  Minor  Surgery,  and  Bandaging.  Fifth  Edition,  Enlarged  and  Im- 
proved. By  Orville  Horwitz,  b.s.,  m.d.,  Clinical  Professor  of  Genito- Urinary  Surgery 
and  Venereal  Diseases  in  Jefferson  Medical  College  ;  Surgeon  to  Philadelphia  Hospital,  etc. 
With  98  Formulas  and  167  Illustrations. 

No.  10.  MEDICAL  CHEMISTRY.  Fourth  Edition.  Including  Urinalysis,  Chemistry  of 
Milk,  Blood,  etc.  By  Henry  Leffmann,  m.d..  Professor  of  Chemistry  in  Pennsylvania 
College  of  Dental  Surgery  and  in  the  Woman's  Medical  College,  Philadelphia. 

No.  II.  PHARMACY.  Fifth  Edition.  Based  upon  Professor  Remington's  Text-Book  of 
Pharmacy.  By  F.  E.  Stewart,  m.d.,  ph.g.,  late  Quiz-Master  in  Pharmacy  and  Chemistry, 
Philadelphia  College  of  Pharmacy ;  Lecturer  at  Jefferson  Medical  College. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOLOGY.  Illustrated.  By  Wm. 
R.  Ballou,  m.d..  Professor  of  Equine  Anatomy  at  New  York  College  of  Veterinary  Sur- 
geons ;   Physician  to  Bellevue  Dispensary,  etc.     With  29  graphic  Illustrations. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE.  Third  Edition, 
Illustrated.     By  George  W.  Warren,  d.d.s.,  Pennsylvania  College  of  Dental  Surgery. 

No.  14.  DISEASES  OF  CHILDREN.  Colored  Plate.  By  Marcus  P.  Hatfield, 
Professor   of  Diseases  of  Children,  Chicago  Medical  College.      Third  Edition.     Just  Ready. 

No.  15.     GENERAL  PATHOLOGY.  Illustrated.  By  A.  E.  Thayer,  m.d.,  etc. 

No.  16.  DISEASES  OF  THE  SKIN.  By  Jay  F.  Schamberg,  m.d..  Professor  of  .Skin 
Diseases,  Philadelphia  Polyclinic.      Third  Edition,  Revised.      ic6  Illustrations. 

No.  17.     HISTOLOGY.     Illustrated.     By  H.  H.  Gushing,  m.d.  "  rrepai-iug. 

No.   18.      SPECIAL  PATHOLOGY.     Illustrated.      By  same  author  as  No.   15.     Just  Ready. 

No.  19.     KYLE— EAR,  NOSE,   AND  THROAT.     Illustrated.  In  Press. 

43 


PRACTICAL  GYNECOLOGY 

A  Modern  Comprehensive  Text-Book 
By  E.  E.  MONTGOMERY,  M.D. 

Professor  of  Gynecology,  Jefferson  Medical  College?   Gynecologist  to  the  Jefferson  Medical 

College  and  St.  Joseph's  Hospitals;   Consulting  Gynecologist  to 

the  Philadelphia  Lying-in  Charity 

WITH  FIVE  HUNDRED  AND  TWENTY-SEVEN 
ILLUSTRATIONS 

Nearly  all  of  which  have  been  Drawn  and  Engraved  Specially  for  this 
"Work,  for  the  most  part  from  Original  Sources 

OCTAVO.    819  PAGES.    CLOTH,  $5.00 ;  LEATHER,  $6.00 


From  THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION, 

"  Fashion  in  medical  book-making  seems  to  be  running  to  the  composite,  which 
may  be  advantageous  and  the  means  of  producing  a  better  book  than  one  written  by 
an  individual.  It  may  be  the  old-fashioned  notions  of  the  reviewer,  but  he  belives  in 
the  old  idea  of  one  book,  one  author,  and  he  should  have  all  the  responsibility,  all  the 
criticism,  and  all  the  glory  that  attach  to  it.  The  composite  is  likely  to  be  written 
under  a  '  rush '  order — so  much  space,  in  so  much  time,  for  so  much  money.  The  work 
before  «s  is  the  work  of  one  individual,  and  the  personality  of  that  individual  is  evident 
through  the  whole  book.  .  .  .  The  result  shows  painstaking  effort  in  every  detail, 
in  conciseness  of  statements,  in  arrangement  of  subjects,  and  in  the  systematic  order 
and  completeness  in  which  each  is  considered.  ,  .  .  The  author  is  neither  too 
radical  nor  too  conservative  in  his  consideration  of  the  conditions  that  may  need  radical 
operations.  In  the  introduction  he  tells  us  that  the  true  gynecologist  must  be  '  so  con 
servative  that  he  will  sacrifice  no  organ  whose  physiologic  integrity  is  capable  of  being 
restored ;  so  bold  and  courageous  that  his  patient  shall  not  forfeit  her  opportunity  for 
life  or  restored  health  through  his  failure  to  assume  the  responsibility  of  any  operative 
procedure  necessary  to  secure  the  object.'  This  is  the  basal  idea  that  permeates  the 
book  :  the  ultra-radical  operator  will  find  no  endorsement,  and  the  *  tinkering*  gynecologist— 
he  who  treats  all  diseases  of  women  by  means  of  a  pledget  of  cotton  and  a  speculum- 
no  encouragement  in  its  pages. 

^  "The  book  is  one  that  can  be  recommended  to  the  student,  to  the  general  practi- 
tioner— who  must  sometimes  be  a  gynecologist  to  a  certain  extent  whether  he  will  or  not 
— and  to  the  specialist,  as  an  ideal  and  in  every  way  complete  work  on  the  gynecology  of 
to-day — a  practical  work  for  practical  workers." 


DESCRIPTIVE  CIRCULAR  UPON  APPLICATION. 

44 


NOW     READY 


DISEASES  OF  THE 

SKIN 

Their  Description,    Pathology,    Diagnosis,  and    Treatment,  with 
Special   Reference  to   the   Skin   Eruptions  of  Children. 

By    H.    RADCLIFFE    CROCKER,    M.D. 

*Physici3.n  to   the   Department   of  Skin   Diseases,    University    College   Hospital,   London 


MESSRS.  P.  Blakiston's  Son  &  Co.  take  pleasure  in  announcing  the 
publication  of  the  new  third  revised  edition  of  Diseases  of  the  Skin,  by 
Dr.  H.  Radcliffe  Crocker.  This  announcement,  coming  at  a  time  when 
recent  progress  in  dermatology  makes  an  authoritative  work  upon  the  subject  a 
positive  necessity,  is  considered  of  special  importance  by  the  publishers,  and  it  is 
believed  the  same  view  will  be  taken  by  the  profession.  Crocker  on  the  Skin  is 
a  book  built  entirely  upon  superior  merit.  It  has  been  acknowledged  by  the 
American  medical  press  as  "the  best  text-book  in  the  English  language."  The 
new  third  edition  maintains  this  high  standard  of  excellence. 

It  is  a  safe,  accurate,  eminently  practical  and  strictly  modern  treatise,  well 
and  clearly  written  by  a  man  of  large  experience  and  most  excellent  judgment. 
Though  completely  scientific,  it  is  written  in  such  a  happy  manner  that  the  tyro 
may  follow  the  writer  almost  as  readily  as  the  expert  on  diseases  of  the  skin.  It 
will  be  seen,  therefore,  that  it  appeals  to  general  practitioners  as  well  as  specialists, 
while  to  the  student  it  will  serve  as  a  valuable  guide  when  he  enters  upon  the 
more  arduous  task  of  practice. 

The  etiology,  symptomatology,  pathology  and  minute  anatomy,  constitutional 
conditions,  diagnosis  and  treatment  of  each  disease  mentioned  is  fully  entered 
upon,  the  therapeutics,  dietetics,  and  general  regimen  coming  in  also  for  their 
due  share  of  attention,  great  strength  in  the  accuracy  of  statement  and  method 
and  clearness  of  definition  and  differentiation  being  shown.  The  newer  remedies 
and  bacteriological  researches,  in  their  bearing  upon  dermatology,  are  carefully 
noted ;  and  particular  attention  is  paid  to  eruptions  as  they  occur  in  childhood. 
This  latter  feature  is  one  usually  much  neglected  in  general  text-books,  and  its 
value  is  the  greater  from  the  known  practical  and  extensive  experience  which  the 
author  has  had  in  this  field. 

The  book  proves  Dr.  Crocker  to  be  closely  in  touch  with  the  work  and 
teachings  of  modern  dermatology  ;  and  he  has  sifted  from  the  vast  accumulations 
of  recent  literature  the  facts  and  opinions  which  have  a  definite  value  and  are 
worthy  of  permanent  record.  The  illustrations,  too,  showing  as  they  do  the 
morbid  conditions  of  the  different  structures  affected  in  diseases  of  the  skin,  are 
a  not  unimportant  feature. 

Many  valuable  additions  to  the  text  are  noted  in  the  new  third  edition  of 
this  standard  work.  The  whole  book  has  been  systematically  gone  over  and 
numerous  changes  made  where  recent  progress  in  dermatology  and  a  more  exact 
knowledge  of- the  subject  has  dictated.  The  result  is  a  work  every  page  of  which 
bears  the  impress  of  honesty,  thoroughness,  and  large  personal  experience. 


Third    Edition,   Thoroughly   Revised,   with  New    Illustrations.      Octavo  ;    1400  pages. 
Cloth,  $5.00  ;   Leather,  $6.00. 

45 


Carpenter  on  THE  MICROSCOPE 


AND  ITS  REVELATIONS 


EIGHTH  E-DITIO/f 

Edited  by  W.  H,  Dallin^cr,  D.Sc,  D.C.L,  F.R.S. 


With  23  Plates  and  nearly  900  Engravings 


OCTAVO.    1181  PAGES.     CLOTH,  $8.00  j   HALF  MOROCCO,  $9.00 


*^*  Eigfht  of  the  chapters  have  been  entirely  rewritten  and  the  text 
throttgfhout  reconstructed,  enlarged,  and  revised  with  the  aid  and  advice 
of  E.  M.  Nelson,  ex-President  of  The  Royal  Microscopical  Society; 
Arthur  BoIIes  Lee,  author  of  ^^The  Microtomist's  Vade  Mecum^;  Dr.  E. 
Crookshank,  the  well-known  Bacteriolog:ist ;  Prof.  T.  Bonney,  F.R.S.; 
"W.  J.  Pope,  F.I.C.,  F.C.S.,  etc..  Chemist  to  the  GoIdsmith^s  Technical 
Institute ;  Prof.  A.  "W.  Bennett,  Lecturer  on  Botany  at  St.  Thomas*  Hos- 
pital ;  and  F.  Jeffrey  Bell,  Professor  of  Comparative  Anatomy  and  Zoology, 
King^s  College,  London. 

*:j:*A  thorough  and  complete  revision  of  the  entire  text  has 
been  made ;  eight  chapters  have  been  entirely  reconstructed,  and 
everything  of  importance  to  Microscopy  which  has  transpired  in 
the  interval  has  been  noted.  This  applies  to  the  theory  of  the 
Microscope  as  well  as  to  its  use.  Many  new  illustrations  have 
been  included  and  it  has  been  very  materially  increased  in  size. 


"CARPENTER"  is  the  only  complete  and  exhaustive  modern  work  on 

the  Science  of  Microscopy 

46 


Diseases  of  tKe  Digestive  Tract 

Their  Special  Pathologfy-y  Diagnosis^  and  Treatment.  With 
Sections  on  Anatomy  and  Physiology^  Analysis  of  Stomach 
and  Intestinal  Contents^  Secretions^  FeceSy  Ufine^  Bacteria^ 
Parasites^  etc.^  Surgery^  Dietetics^  Diseases  of  the  Rectom^  etc« 

AN  EXHAUSTIVE  SYSTEMATIC   TREATISE 

By  JOHN  C.  HEMMETEH,  M.D. 

Professor  in  the  Medical  Department  of  the  University  of  Maryland ;  Consultant  to  the  University  Hospital  and 

Director  of  the  Clinical  Laboratory,  etc.;  formerly  Clinical  Professor  of  Medicine 

at  the  Baltimore  Medical  College,  etc. 


DISEASES   OF  THE  STOMACH.    Third  Edition. 

With   15   Plates   and  41    other  Illustrations,  some  of  which 
are  printed  in  Colors.      Octavo.      894  pages. 

Cloth,  $6.00  ;  Sheep,  ^7.00 

DISEASES   OF  THE  INTESTINES.    Two  Volumes. 

With    19   Plates  and   no  other  Illustrations,  some  of  which 
are  printed  in  Colors.      Octavo.      142 1  pages. 

Vol.- I.  Anatomy,  Physiology,  Pathology,  Diagnosis,  Thera- 
peutics, Intestinal  Clinic,  etc.  Cloth,  $5.00  ;  Sheep,  $6.00 

Vol.  II.  Appendicitis,  Occlusions,  Intestinal  Surgery,  En- 
teroptosis.  Infectious  Granulomata,  Neuroses,  Parasites,  Dis- 
eases of  the  Rectum,  etc.  Cloth,  ^5.00 ;  Sheep,  ^6.00 

*5j;*  These  books  form  a  complete  treatise  on  Diseases  of  the  Digestive  Tract. 
The  subject  is  covered  thoroughly  and  systematically  by  an  author  of  well-known 
reputation  and  ability.  The  results  of  recent  investigation,  by  which  so  much 
progress  has  been  made  in  the  Pathology,  Diagnosis,  and  Medical  and  Surgical 
Treatment  of  disorders  of  the  intestinal  tract,  make  their  issue  at  this  time  of 
special  importance.  They  are  handsomely  illustrated,  exhaustive,  and  written 
for  the  general  practitioner,  taking  into  special  consideration  American  habits  of 
hving,  diet,  and  climate. 

"  We  wish  to  express  unqualified  approval  of  the  tendency  which  is  shown  to  emphasize  the 
simple  and  more  practical  methods  of  diagnosis." — Neiu  York  Aledical  Journal,  Review  of  "  Dis- 
eases of  the  Stomach." 


DESCRIPTIVE  CIRCULAR  UPON  APPLICATION 

47 


NEARLY  READY 


Edgar^s  Obstetrics 


A  NEW  TEXT-BOOK 


By  J.  CLIFTON  EDGAR,  M.D. 

Professor  of  Obstetrics,  Medical  Department  of  Cornell  University,  Nc-w  York  City;  Physician  to  Mothers'  and 
Babies'  Hospital  and  to  the  Emergency  Hospital,  etc. 


Octavo,  about  JOOO  Pages;  900  Illustrations 


The  Illustrations  in  Edgar's  Obstetrics  surpass  in  number,  in  artistic 
beauty  and  in  practical  worth  those  in  any  book  of  similar  character.  They  are 
largely  from  original  sources.  Those  which  follow  other  works  have  been 
redrawn  with  modifications  so  that  the  entire  series  is  new.  All  have  been  drawn 
by  artists  of  long  experience  in  this  department  of  medical  illustration,  and 
whenever  of  advantage  to  do  so  are  reproduced  at  a  stated  scale. 

No  attempt  has  been  made  at  display.  When  a  small  cut  serves  every  pur- 
pose drawings  are  not  reproduced  to  occupy  a  large  space;  when  black  and  white 
are  equally  expressive  an  elaborate  colored  plate  has  not  been  used.  So  far 
as  possible,  cuts  have  been  inserted  in  the  text  where  they  are  wanted  and  where 
the  eye  catches  them  at  the  place  the  text  explains  them.  Relative  importance 
has  determined  the  selection,  the  size,  and  the  character  of  each  figure.  There 
are  many  explanatory  diagrams  which  add  greatly  to  the  teachijig  values  of  the 
pictures.  The  aim  of  author,  artist,  and  publisher  has  been  to  make  a  series  of 
pictures  useful  to  the  student  and  reader,  and  no  time,  labor,  or  money  has 
been  spared  to  gain  this  end.  The  lack  of  uniformity  in  quality  and  failure  to 
observe  scale — the  great  faults  in  books  on  this  subject — have  been  kept  constantly 
in  mind,  and  every  endeavor  has  been  made  to  avoid  similar  defects. 

The  Text  has  been  prepared  with  great  care.  The  author's  extensive 
experience  in  hospital  and  private  practice  and  as  a  teacher,  his  cosmopolitan 
knowledge  of  literature  and  methods,  and  an  excellent  judgment  based  upon  all 
these  fit  him  specially  to  prepare  what  must  be  a  standard  work  for  both  students 
and  physicians. 

In  the  text  as  in  the  illustrating,  uniformity  and  consistency  have  been  kept 
constantly  in  view.  The  subjects  of  monstrosities  and  malformations,  for  example, 
do  not  take  up  space  which  could  be  better  used  for  more  practical  and  useful 
matters,  though  these  topics  like  others  of  their  class  receive  due  consideration 
and  are  illustrated  by  a  very  complete  series  of  small  figures.  Nothing  of 
importance  remains  unsaid,  and  the  relative  value  of  each  subject  has  been  care- 
fully planned  out  and  fixed  by  deliberate  thought.  The  author's  reputation  is 
sufficient  guarantee  of  the  merit  of  this  book ;  the  publishers,  however,  ask  a 
comparison  with  other  works,  with  confidence  that  this  will  be  found  the  most 
useful. 

4B 


Wi 


RST^IMi 


